July 2, 2009

Whats the new spelling for the AMA? S-E-R-M-O

Spelling (spĕl’ĭng) n.

  1. The forming of words with letters in an accepted order; orthography.
  2. The art or study of orthography or the way in which a word is spelled.

Whoa . . . just ahead of a 21% cut in physician salaries we have an epic battle shaping up within the physician community. The AMA, long the Godfather and voice of physicians around the country, apparently is feeling the heat from a younger, more svelt upstart from across (cyber)town. I have just received back to back emails from Sermo CEO Daniel Palestrant essentially declaring his succession from the physician union. This comes at a critical time when further fracturing of physician leadership and political strength put in jeopardy the opportunity for the physicians to have a unified voice (or is it because the stakes are so high that this group is compelled to speak up?):

The leading missive from 7/1/09 (might require log in):

Dear Dr. Shreeve,

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

The AMA has drawn its power from the support of the physician community. The waning membership reflects our objection as the AMA has failed us consistently for over 50 years. Make no mistake, the debate within the AMA about how to stop their membership decline is not new.  What is new is the lengths to which the AMA appears willing to go to deceive the public on this topic.  The AMA routinely claims that their membership is 250,000 practicing physicians.  At best, this is 25-40% of practicing US physicians and even that claim is based on some stretching of the truth.  The 250,000 total includes a number of non-practicing constituencies, including medical students, residents, and subscribers of the AMA’s journals.  Paying membership is generally accepted to be far lower.  How much lower?  Actual numbers are remarkably difficult to come by.

At this critical moment in history, we cannot watch the AMA fail physicians so completely yet again.  Nor can we stand by and let false perceptions about who speaks for physicians persist. At the very least, all parties should understand the intrinsic conflicts of interest that are in play, and the AMA should be held accountable to these truths.  Better yet, physicians should call for sweeping changes within the AMA.   In the best-case scenario, the AMA will shed its relationships with insurers and abandon tactics that take advantage of physicans to generate millions of dollars in revenue.  It is an inherent conflict of interest to claim advocacy for physicians while profiting from a reimbursement system that makes it increasingly difficult for physicians to practice medicine.

The flight from the AMA signals that physicians don’t believe the AMA is willing to make these changes. The longer that the public and our lawmakers cling to the perception that the AMA represents the voice of US physicians (and the AMA succeeds in perpetuating this), the more imperiled the medical profession will be and with it the broader US healthcare system.  It’s time to turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.

There can be no healthcare reforms that have any chance of succeeding without buy-in from physicians.  As a country, we cannot risk another failed reform effort.  As physicians, we cannot risk letting the AMA represent our interests.  This is our time to educate the public about which voices truly represent us and our commitment to our patients.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

The follow on upper cut (From 7/2/9):

Dear Dr. Shreeve,

Yesterday I posted on Sermo about the need for a new voice to represent physicians. The Sermo community’s response was clear. 2,400+ physicians voting in less than 24 hours. 90% say that the AMA does not represent them. That is a bold statement and the general public will take note.

The need for physicians in this country to have a strong voice has never been greater. And Sermo, a community of well over 100,000 US Physicians, needs to make its voice heard. Yesterday’s posting was the beginning of a regular series that will make your voice heard on issues critical to our profession. Results from these postings will be publicized to the media.

Believe it or not, we are already making dramatic progress. I have been contacted by major media outlets who are interested in what physicians on Sermo have to say. Beginning next week our voice will be heard.

Add your voice to the first topic:

The Biggest Risk to US Physicians Today: The AMA

Sincerely,

Daniel Palestrant, MD
CEO & Founder
Sermo Inc.

I have commented about Sermo before (here and here). I think it can be a useful tool – the virtual lounge if you will – which I totally get. Some of the hallway conversations were useful, but I had other settings in which to engage to my clinical and personal satisfaction. And just like the real thing, I never felt comfortable hanging out in the posh lounge with slightly better food when all my patients, colleagues, and fellow health care workers were sent somewhere else. It is the same discomfort I feel on the rare occasions I have flown first class and sat uncomfortably watching all the “regular” people pass pass on the way to the back of the plane.

Obviously a Sermo style virtual lounge has alot of potential and possibilities. While some of my previous comments can be taken as somewhat down on the platform, I am generally very much in favor and supportive of what Sermo is doing. In fact, I believe the collective intelligence within the network is a wonderful place to harness the cognitive surplus of physicians. Moreover, online communities of experts who can share real medical knowledge in real time, discuss and comment in warp speed peer review, and allow a business commodity to be created from voyeurism certainly has earned my respect.

The breakthrough is not in the message nor even the messenger, it is the manner in which I am getting this message that is most impressive. 100,000 physicians strong (and growing), online and interactive, and now muscling up for the biggest fight of their life. Perhaps most useful of all, is the ability to aggregate the physician voice into a common unified message. My articles above highlight the role of aggregators, and this specific type of network effect grows in influence and power to the point of being a  political force to reckon with. Perhaps the 100,000 member barrier represents the political tipping point to take on the slothful big brother?

Should be interesting to follow – looking forward to seeing if the new kingpin has the staying power to dislodge the king. Looks like he has certainly swiped the scepter.

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Filed under Change Agents, Consumerism, EHR

June 23, 2009

The Myth of Prevention and EHR’s?

Prevention (prĭ-vĕn ’shən) n.

  1. Preventing or slowing the course of an illness or disease
  2. Intended or used to prevent or hinder; acting as an obstacle
  3. Carried out to deter expected aggression by hostile forces.

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!). With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyros, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition). The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers - get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next generation medicine.

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Filed under EHR, Healthcare, Prevention, Quality, Transparency

June 16, 2009

#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!

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Filed under EHR, Industry, Leadership

June 1, 2009

VistA – Its Now or Never

Never (nĕv’ər) adv.

  1. Not ever; on no occasion; at no time
  2. Not at all; in no way; absolutely not

Recently president Barack Obama told his Organizing for America fanbase that is was “Now or Never” for healthcare reform, “If we don’t get it done this year we are not going to get it done.” While this is a little dramatic, I think the point is that the stars are truly aligned to actually get something done this year. We are beyond life support in healthcare, let alone worrying about the ~50 trillion of unfunded healthcare liabilities already obligated as part of Medicare system. We absolutely need to shift the paradigm within health care and I am hopeful my little efforts can be contributory.

A major part of any reform effort includes the implementation of Electronic Health Records to bring our physicians into the new millenia. Much has been made about “meaningful use” and standards, and much more will be made of certification and outcomes as the money starts flowing. I have to agree with many of my open source friends who are making loud and passionate pleas to congress to consider including provisions to ensure that these investments have the greatest opportunity to yield a return for the public. I don’t think their message has penetrated the lobbyist fortress that is Washington, DC.

I hope to help the cause by making another plea here. I have been fortunate to be a part of a small group of individuals to recognize that one of our greatest national treasures should be given another opportunity to prove its serviceability in providing the highest care and quality to the most deserving of patients. I speak, of course, of my old friend VistA.  Having see this dignified lady transform state veteran facilities, public health clinics, and modern hospitals into higher performing health organizations, I can only but wonder what would happen if she were given a little makeover what she could do.

VistA has been available for 25 years as part of the Freedom of Information Act. Only within the last five years have serious efforts begun to commercialize the system.While there have been tremendous early successes, the lack of “spread” gives me pause for concern.With all the billions being dedicated to HIT and EHR, I have to think that an excellent public investment would be to extend and build upon VistA as a platform for a specific subsegment of public, state, and federal related facilities. These efforts would be dovetailed into efforts already initiated within the DoD and the VA (who are finally trying to have a single system for their singular patients). It could save hundreds of millions of dollars if these efforts were done openly, collaboratively, and in a true open source fashion.

I believe the event horizon for this opportunity is rapidly narrowing. As the pace of technology and computing advances, the opportunity to retool and reskin VistA is closing. I am concerned that without some direction (clearly none coming from the VA), some leadership (none coming clearly from the community), and some momentum (need to have 25+ Midland size implementations), VistA will become an interesting footnote in the history of HIT. The flood of new money will lock in current proprietary solutions and the opportunity to fundamental disrupt with an open source solution will be lost. This season of opportunity will not be an Endless Summer – the coming stimulus wave may be VistA’s last ride.

Its now or never.

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Filed under EHR, VistA

May 26, 2009

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.

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

May 26, 2009

Blog Rally: Raising Awareness for Public Participation in Healthcare X PRIZE Development

Blog Rally (b’lôg răl’ē) adj.

  1. A coordinated, simultaneous presentation of identical or similar material on numerous blogs for the purpose of engaging large numbers of readers and/or persuading them to adopt a certain position or take a certain action.
  2. The simultaneous nature of a blog rally can create the result of joining the efforts of otherwise independent bloggers for an agreed-upon purpose.

We are entering an unprecedented season of change for the United States health care system. Americans are united by their desire to fundamentally reform our current system into one that delivers on the promise of freedom, equity, and best outcomes for best value. In this season of reform, we will see all kinds of ideas presented from all across the political spectrum. Many of these ideas will be prescriptive, and don’t harness the power of innovation to create the dramatic breakthroughs required to create a next generation health system.

We believe there is a better way.

This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50% in a 10,000 person community over a three year period.

The Healthcare X PRIZE team has released an Initial Prize Design and is actively seeking public comment. We are hoping, and encouraging everyone at every opportunity, to engage in this effort to help design a system of care that can produce dramatic breakthroughs at both an individual vitality and community health level.

Here is your opportunity to contribute:

  1. Download the Initial Prize Design
  2. Share you comments regarding the prize concept, the measurement framework, and the likelihood of this prize to impact health and health care reform.
  3. Share the Initial Prize Design document with as many of your health, innovation, design, technology, academic, business, political, and patient friends as you can to provide an opportunity for their participation

We hope this blog rally amplifies our efforts to solicit feedback from every source possible as we understand that innovation does not always have a corporate address. We hope your engagement starts a viral movement of interest driven by individual people who realize their voice can and must be included. Let’s ensure that all of us – and the people we love – can have a health system that aligns health finance, care delivery, and individual incentives in a way that optimizes individual vitality and community health. Together, we can ensure the best ideas are able to come forward in a transparent competition designed to accelerate health innovation. We look forward to your participation.

Special thanks to Paul Levy for both demonstrating the value of collaborative effort and suggesting we utilize a blog rally for this crowdsourcing effort.  Participating bloggers and media include include:

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      Filed under Uncategorized

      May 22, 2009

      Death to Innovators – The Tragedy of Healthcare Innovation

      Tragedy (trăj’ĭ-dē) n.

      1. A disastrous event, especially one involving distressing loss or injury to life
      2. A tragic aspect or element.
      3. A drama or literary work in which the main character is brought to ruin or suffers extreme sorrow, especially as a consequence of a tragic flaw, moral weakness, or inability to cope with unfavorable circumstances.

      The Advisory Board to the Health 2.0 Conference have been rehashing the recent conference in preparation for the fall program. We are continuing to try to push the boundaries of how to highlight bleeding edge innovations (dessert) and the new tools and technologies (eye-candy), but trying to be disciplined in challenging the community to put up their hard core case studies (nutritious tofo in the words of Esther Dyson) that demonstrate why this movement actually matters. This latter one requires thoughtful discipline, and hard data, from people trying to do very hard things (like obtain accurate personal health data from disparate sources, help consumers understand and optimize health value, and show how these new models of care actually lower cost). We look forward to producing a great program and I will keep you posted on these conversations.

      The reason it is so hard to “do the right thing” in health care is that the current environment is a conspiracy of connundrums - no accountabilty, no transparency, rules/regulations, culture, binding contracts, third party payments, behavioral choices, lack of evidence, etc ad nauseaum. A real world example of how this plays out can be seen in the Vicious Cycle of Healthcare Innovation. This article highlights what happens when health care providers “do the right thing” but are rewarded with less money, which then kills off not only their desire but also their capability to do the right thing. Its a beautiful mechanism to ensure that the status quo never changes. This “Death to Innovators” concept has been highlighted by Intermountain Healthcare (pneumonia), Virginia Mason (back pain), and health innovators like Rushika Fernandopulle , MD at Reinnassance Health.

      These tragedies have to be overcome. Given the grip of the medico-industrial complex, and their lobbying minions in DC, the only hope I have is that an entirely new system of health can begin to develop and emerge “off the grid” for the current non-consumers of healthcare. From this toehold, and from early and small efforts of the myriad groups seeking to change the financing of healthcare, I am hopeful that innovation can emerge that will align incentives, coordinate care delivery, improve outcomes, and be rewarded appropriately for these results.  That is why I am involved in the various efforts to not only bring innovation to light but also demonstrate that these models can flourish.

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      Filed under Conferences, Health 2.0, Innovation

      May 6, 2009

      Single Sentence Statement: Health Value as a messaging challenge

      This is a cross post to some of my writing over at the Healthcare X PRIZE blog

      The focus on health care value is a powerful organizing principle, but communicating this concept in an elevator pitch is challenging

      The Healthcare X PRIZE continues to build momentum as we receive a steady stream of inquiries regarding this $10MM competition. While many of the inquiries are regarding timing, application, and registration process, we have also been receiving a number of high quality request for information from technology companies, academic organizations, and communities who are interested to understand how they can participate. In fact, the most passionate inquiries seem to come from community based organizations who have a clear vision of how the community can be architected to function as a single entity that maximizes health value.

      It is great to see how the X PRIZE can inspire this type of thinking. However, we have received some feedback that the health value story is a little difficult to grasp. Admittedly, it feels like it takes two or three sentences to explain what we mean by health value, how community health is related to that, and how individuals are connected to and influence the community. This is in contrast to the single statements of other prizes that immediately evoke a powerful and clear notions of what is the prize is about. As an example of the single sentence statements that create a singular focus:

      These are all clear and compelling; single statements that can be pitched in an elevator and understood by a child. They also represent significant scientific and technical breakthroughs that are understood and can be systematically worked through. However, the Healthcare X PRIZE is a different animal. It is actually a prize designed to change a system (and a very complex one at that). With approximately 20% of the GDP involved in the industry we are trying to reform, it is worthy of an X PRIZE type effort although many believe we are pushing the boundaries of the X PRIZE framework in designing a systemic prize versus something more confined, constrained, and ultimately more conservative.

      But it is a challenge we are willing to take on.

      We believe that health value is the right organizing principle, but perhaps we communicate the same message in a different way that drives home the point in a more singular fashion. Perhaps we need to focus more on the “healthy community” aspect (using the health value measurement framework), ala the huge success we are seeing with initiatives like Shape Up Rhode Island. Perhaps we need to shift to focus on a leading indicator condition like the Heart of New Ulm (which to impact would still require the systemic changes we seek). Or, perhaps, we just need to keep preaching the Health Value story with direct outreach, clear examples, and compelling case studies.

      We look forward to your feedback as we continue to evolve the messaging of the Healthcare X PRIZE. Given the potential impact of the prize to demonstrate that radical transformations within health care are possible, we look forward to developing the most compelling single sentence statement.

      Would love to get your feedback.

      2 Comments

      Filed under Value, X PRIZE

      April 23, 2009

      Recap: Building Health 2.0 Into The Delivery System

      Recap (rē-kăp) n.

      1. To replace a cap or caplike covering on: recapped the bottle.
      2. To restore (a used tire of a motor vehicle) to usable condition by bonding new rubber onto the worn tread and lateral surface.

      We had a busy session yesterday during my panel. Besides the irritating AV problems (in/out sound, survey probs, etc), we had a pretty good conversation on stage with 4 innovative provider types who are making a real difference in health care. The slides that we used to set the stage:

      KEY POINTS:

      1. Integrated Delivery Systems rock. The integrated systems deliver the best results. Period. But what about the other 85% – what can they learn from them? How can we distributed thier lessons learned to others who are trying to create “systems”. Both Group Health and the Dartmouth Clinics have acheived amazing results. Of interest, audience selected by 55% integrated delivery system, and 35% chose a small group practice.
      2. Transparency Rules. We opened up our second discussion going just right to the heart of the matter – What the heck happened with ePatient Dave, BIDMC, and Google Health? While much media has been generated regarding the ptifalls and perils, I think Roni Zieger (rhymes with “Tiger” as he unfortunately had to correct me) hit the nail on the head by essentially saying “don’t throw out the baby with the bathwater”. Essentially ePatient Dave has a very complex history – 92 ICD9 codes during the course of his illness – and essentially the entire data stream was released to his PHR. This was flawlessly execute by BIDMC to Google but exploded as ePatient Dave actually looked at what was sent over. The signal to noise ratio was impercetible (so much noise!). While there was no harm done, ePatient Dave appropriately called FOUL! regarding the potential for error, problem, and pain. This created a juicy story for the media which created a potential crisis for both BIDMC and Google. In Zen-like Fashion, John Halamka immediately diffused the situation by calling a meeting with all the players, openly discussed the concerns, made both a short and long term fix, and then putting together a strategy on how to deal with this issues in the future.  While the media story was the problem with the administrative claims data being shared, the real story was how – in a health 2.0 world – being transparent allows troubles to be trumped tersely. We heard directly from Roni, from John Halmka, and also ePatient Dave who spoke out as well. It was a great session, great conversation, and great example of the brave new world of health 2.0.
      3. Death to Innovators. Rushika had alot of great comments regarding both the opportunity and the challeng faced by innovators within the system. He was shunned, excluded, cursed, vilified, and all but tarred and feathered in Boston as he chose to focus on optimizing health of individuals to the exclusion of feeding the rapacious “system” as now constituted. He has pushed the boundaries in terms of adopting and expanding on the notion of the medical home, customer service, payment mechanism, etc. But serious challenges exist to reform the regulatory, the payment, and the entire culture. Rushika mentioned that health 2.0 will allow the patients to “vote with their feet” as they move to practices who deliver in this way.
      4. No Money, No Change! The bottom line was that all the good, bad, and ugly of our health care system has some roots in the financial incentives that are created. We need to fundamentally need to get to the root of this in order to create/reform the next generation system. If the actual financing of health care does not change, there is little hope that the delivery can change. An interesting insight into this was Group Health – which financially aligns the physicians payment to quality outcomes. According to James, “listen, changing the culture toward quality outcomes is hard enough – trying to do it when its against your self interest to do it is impossible”.  Even for innovators like Myca, there rate limiting step is potentially the payment mechanism as well (although they have a very juicy $250B cash payment market to go after!).

      We did not have enough time to discuss, or take questions, but I believe we were able to accomplish our stated objective:

      1. Sense of realism of the challenges, but more importantly an optimism for the potential of Health 2.0; 2
      2. A realization that not only are new entrants creating systems from scratch based on this new paradigm but large, established players are leveraging these tools/technology as well; and finally,
      3. The possibility to transform our health system will happen both inside and outside the current system to ultimately result in a high performing, value-based, next generation health system to increases individual vitality and improves community health.

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      Filed under Conferences, Health 2.0, Health Finance, Innovation

      April 22, 2009

      Building Health 2.0 Into the Delivery System

      Delivery (dĭ-lĭv‘ə-rē) n.

      1. The act of conveying or delivering, the act of transferring to another.
      2. Something delivered, as a shipment or package.

      I am enroute to Boston for the Health 2.0 conference. I look forward to moderating a great session in the afternoon – “Great Debate #2 – Building Health 2.0 Into The Delivery System”. I have an awesome group of panelist as well as presentors (see below) and look forward to a lively session.

      The original debates about Health 2.0 framed the definition as either Web 2.0 tools being adopted by health care or a much larger vision of how those enabling technologies would transform the delivery system itself. This session is the next installment in the quest to answer the question about the role, opportunity, and the ultimate impact Health 2.0 will have on health – and how this new paradigm alters relationships between patients, providers, payers, and the system itself.

      Health 2.0 has already changed the landscape of health by delivering tools and technology that empowers patient communities, results in connected physicians, forces transparency to the system, and restores the patient to the center of the health experience. However, much of this has happened at the margins, outside the traditionally paternalistic medical-industrial system. While this has populists and even revolutionary appeal, the quest for far broader adoption of these concepts must penetrate deeper into the underbelly, into the very heart of the plumbing, to attack the calcified hairball where a thousand health revolutions have died before.

      During my session we will explore the current state of the movement, to assess how Health 2.0 is now changing the actual delivery of health care. The previous Great Debate #1 will have discussed the role of information therapy, essentially curated content from a trusted heath advisor, as the first beach head from which to continue to infiltrate the health delivery system. We will discuss the current state of the art with the thought leaders actually implementing Health 2.0 – from small independent clinics to large integrated delivery systems – who are adopting and adapting these enabling technologies as part of a larger transformation to a next generation health system.

      My aim for the session is that you will leave with three memes for further exploration:

      1. A sense of realism for the challenges, but more importantly an optimism for the potential impact of Health 2.0 in this health reform cycle;
      2. An awareness that new entrants are creating systems from scratch outside the current health care paradigm, but that established players are innovating inside with using similar tools/technology; and finally
      3. An appreciation that the traditional paternalism (structural, cultural, regulatory, and political) inherent in medicine is giving way to the participatory nature of Health 2.0

      Together, these trends will serve as catalyst to transform the finance, delivery, and incentives our current system into manner that creates a patient-centered, high performance, value-based, next generation health system (”Health 2.0″) that  increase individual vitality and the health of communities.

      As part of the session, we will also see presentations from three different platforms, who based on their collective recent media blitz, are clearly at the bleeding edge of a brave new world full of possibilities. The focus will be on transactional capabilities and overall utility for real patients trying to manage real health information in the real world. We look forward to learning from Googles forays into data sharing, Myca’s new paradigm shifting EHR/PHR, and how Kaiser Permanent continues to extend, deepen, and broaden their relationship with their patients using KPConnect.

      The Bios from our presentors is found below:

      Roni Zieger, MD
      Project Manager
      Google Health

      Dr. Zeiger is a Product Manager at Google where he helps lead Google Health and also works on improving the quality of health-related search.  He has worked as a primary care physician, in urgent care, and has served as a Clinical Instructor of Medicine at Stanford University School of Medicine. Dr. Zeiger received his MD from Stanford and completed an internal medicine residency at the University of California, San Francisco.  He was a fellow in medical informatics at Veterans Affairs in Palo Alto, California, and received a masters degree in biomedical informatics from Stanford University.

      Sean Khoizon, MD, MPH
      Medical Director
      Hello Health / Myca

      Dr. Khozin is a founding member and practicing physician at Hello Health, a technology-enabled medical care delivery system that makes healthcare more accessible for patients and practicing medicine more streamlined for physicians. By using the Hello Health platform, patients can schedule an appointment online to see their physicians in the office or communicate with them by email, text messaging, and video chat. For doctors, the platform reduces overhead and creates new channels of communication with patients. Hello Health has developed a web-based platform that creates a patient-centric environment powered by social networking tools to connect and share information with healthcare providers. The technology is also a fully integrated electronic medical record and practice management system.
      Ted Eytan, MD
      Clinical Innovation
      Kaiser Permanente

      Dr. Eytan currently works as a Medical Director for Delivery Systems Operations Improvement for the Permanente Federation, LLC. His experience is in working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.  Dr. Eytan is board certified in family practice. He has relocated to Washington, DC, from Seattle, working in the area of patient-centered health care enabled by technology, with organizations including the California Healthcare Foundation.  He attended medical school at the University of Arizona. He received his master’s of public health degree from the University of California, Berkeley, and his master’s of science, health services degree from the University of Washington. He completed his residency training at Group Health and his fellowship training in the Robert Wood Johnson Clinical Scholars Program at the University of Washington in 2000. His particular interests are patient and family involvement in care, health information technology, and supporting the health and diversity of communities.

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      Filed under Conferences, Health 2.0, Innovation, Value

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