Topol's Healthcare in American - At a Crossroads of Innovation and Ossification

I recently read Eric Topol’s Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care.  I highly recommend it.  Dr. Topol’s main premise is that innovative deconstruction of people (patients) into their more base components- (their DNA, RNA and proteins), will help us design better, more personalized treatments for a host of diseases.  

This relates to the science of pharmacogenetics, how our genetics individualize our respond to drugs.  This is in contradistinction to the current pharma model- treat as many people as possible even if the benefits are modest for most.  

Unfortunately, as Topol points out, medicine as an institution, and physicians in particular, have not kept pace.  The system is relatively ossified.  Through a combination of bureaucracy and tradition, medical education has not changed substantially since the last great paradigm shift, Flexner Report, in 1910.  In the face of an information explosion, the subjects I studied in medical school 25 years ago were similar to those my father learned 50 years ago.  Unless something drastic happens my daughter, currently a pre-med, is likely to have a similar curriculum.  This results is a type of healthcare delivery focused on the hospital, not the clinic, emphasizing the heroic not the chronic.  In part, this mismatch has lead to the US spending almost twice what other nations spend for healthcare with no perceptible benefit.  This is not sustainable.  Of course today’s medical students and residents are more likely to Google for answers than open a book.  Physicians no longer have to be walking encyclopedias.  However , the system continues to value test taking over personality.  I personally believe the best test takers do not make the best providers- just the opposite.   

The book regrettably gives short rife to telemedicine and opportunities for collaboration.  With the information explosion, no single provider can have all the answers.  More granular data will only exacerbate this problem.  Healthcare is moving from a one on one sport to more of a team game.  In order to have a sustainable delivery system, each provider will have a role to play to fully realize the value of new, personalized therapies.  Telemedicine can be leveraged to bring the healthcare pyramid, stratified expertise, to the bedside.  Most people think of this as expensive, limited technology.  However, browser based solutions allow telemedicine to be done over devices in your pocket.  Teams can be brought together to enable the right care at the right time.

Overall, I agree with Topol’s primary assessments- granular data will allow more effective, personalized treatments, and that the current educational and care delivery models are ill prepared for these disruptive innovations.  However, ultimately personalized medicine will be a combination of technology and choice.  No therapy, no matter how elegant, is without risk.  The past few decades have taught us that just because we can do something, even extend life, doesn’t mean we should.  The role of the provider and the team will be to understand the patient, their desires and act as a translator in this brave new world of personalized medicine.   

Meeting the Triple Aim Means Accepting Constant Change

Kap Wilkes, Program Manager II

As a sailor I recognize that change is a constant; at every moment the wind and sea require the boat to adjust. Of course these adjustments are not made randomly. I know where I want to end up and I know a lot about my boat and crew.  As a captain and crew that wants to win the race there are a few other things that we have done to increase our odds: we have a plan in place for communicating, we pay attention to the weather, and we have developed our skills and knowledge to be able to quickly adjust. Although the crew on the boat is smart, we have practiced and we are confident in our execution; there are a lot of aspects to keep track of and they are constantly changing.  Some are factors we need to monitor, some are due to the particular people we have working together and others are external to the boat. They all impact us as we move through the course. In fact they are constantly impacting us. We don’t change the game plan mid-race very often, but we are constantly making adjustments to improve our speed and execution. Now here is the thing about sailboat racing, the game isn’t over at the end of one race. We have our eye not only on the finish line but to win the series. To do that, we have to be able to repeat our performance over and over. In between races we continue to hone our skills and build our knowledge; getting ready for the next race. With an eye on winning the series the entire crew engages in the strategic winning cycle.

In the world of health care organizations today, working to improve care to patients, reduce costs, and improve the health of populations, achieving the Triple Aim, is like working to win a sailboat race series.  One of the keys to success is engaging in the strategic winning cycle for handling change and ensuring sustainability. As in the sailboat race, health care organizations have internal and external forces that require agile adjustment to the execution and implementation. Doing this without knowing where you are going, communicating with the rest of the team so they too can make adjustments or checking your surroundings will ensure that you do not cross the finish line first; ever. In fact, if you ignore the interconnected nature of your boat, your crew, and the wind and sea, you will most likely come in dead-last. To avoid this place of distinction is a huge motivator for sailboat crews and for health care organizations too. Because being dead-last means that the people in your community are not receiving the best care possible, or worse, they may lose their local health organization entirely! The strategic planning cycle is dynamic, iterative and it is critical to engage in the process if you want to win improved health for your community:

• Analyzing and planning creates an opportunity to develop strategic objectives to drive an organization toward its mission and vision. Sustainable business strategies are dependent on the active involvement of an organization’s leadership, staff, and board of directors.

• Documenting and communicating the business strategy facilitated through a management framework, such as the Balanced Scorecard, supports the development of critical partnerships, increases staff engagement, and incorporates holistic thinking into planning.

• Implementing and executing the business strategy through carefully selected initiatives operationalizes the strategies; aligning the organization’s actions with its mission and vision.

• Monitoring and adapting progress based on measurable targets, established through a process improvement framework builds capacity within the organization for handling change.

Troubleshooting the strategic winning cycle: if you are already engaged in a strategic winning cycle, but are struggling with working as a team or having trouble with execution then check to make sure your crew knows where you are heading. Your organization’s vision provides everyone with something to aim for and directs your crew’s decisions.  If your organization is at a turning point, perhaps with new leadership or a significant change in your operations or the health care environment, jump into the strategic winning cycle at the Analyze and Plan phase. This is the time to review your surroundings and your plan to see if there are significant course changes that need to be made. If you are well into your implementation be sure to monitor progress so that you can make effective adjustments.  If your boat speed is faltering; check your sails, adjust the helm and put your crew’s knowledge and skills to work.

“Salsafying” Rural Health Care

Sally Trnka, Senior Program Coordinator

I have a friend^* who is a former rural health network director in the great state of Georgia who is really good about coming up with visual representations or activities for the concepts she is trying to communicate.  A couple of years ago she introduced me to a fantastic activity that she did with her Board—they made salsa.  Yep, salsa!  The activity challenged each of her Board members to bring their favorite ingredient in salsa to a meeting.  When they stood around the table, they each put their ingredient into a bowl one at a time; single ingredients going into the bowl.  By the time all the ingredients had been added and mixed together something happened—the whole became indestructible. (Dramatic word used for maximum impact!)  What had been created could no longer be separated and it was better than any of the individual ingredients on their own. 

I have the distinct privilege of working with “salsa”-like organizations every day—a colorful, diverse mix of organizations that come together to address common concerns and tackle mutual goals. Over the last couple of months, I have talked specifically with the Directors of State Office of Rural Health and Flex Program Coordinators who work diligently to support the networks in their states.  In August I was in South Carolina, working with two rural HIT networks and had the distinct pleasure of working in tandem with their Director of Network Activities, Tiffany Simpson-Crumpley, an employee of the South Carolina Office of Rural Health, headed by Director, Dr. Graham Adams.  With her help and guidance, we are able to provide robust technical assistance to those grantees, amongst the others in the state.  In September, I had the honor of sitting in a planning meeting with Karen Madden, State Office Director in New York, who deeply believes in supporting the multitude of rural health networks in her state.   Similar sentiments are shared by Flex Coordinators in Montana, Wisconsin, Florida, Michigan…the list goes on!

More recently I have worked with the Veterans Administration, the National Hospice and Palliative Care Organization and the Minnesota Network of Hospital and Palliative Care, the National Cooperative of Rural Health Networks and the Federal Office of Rural Health Policy.  All of these organizations practice the concept of collectivity; that all of us is better than any one of us.  We need the diverse perspective and experiences of stakeholders in order to ensure that we are able to meet the needs of our customers, partners and patients. 

As we face an increasingly complex health care environment filled with dynamic change, and occasional instability, it is crucial that we look for partnership opportunities at every juncture.  It has been incredibly powerful to see organizations come together with a shared purpose, regardless of competition or different ideas of how to get where they are going.  Ultimately, it needs to be about the patients and the communities we serve.  It needs to be about our increasingly aging population and how we can best serve them as they live out their final years in their rural communities.  About how to address health care disparities and access challenges.  About helping our communities to be happier through health and wellness.  About encouraging our patients to receive care at their local hospitals and clinics because high quality care (at lower costs, most of the time) is available in rural communities. 

Accomplishing all of that under the pressure of rules, regulations and policies determined by our elected officials will be hugely challenging, but there is no need the reinvent the wheel or strike out on your own.  Look for the partnerships, for the mutual-wins and for what is best for your communities, patients and staff, recognizing that your bottom line doesn’t have to decline with partnerships.  Usually, the opposite is true.

Go ahead!  Make salsa!

(* Special thanks to Tara Cramer for this great idea!)

One of the best read ideas of 2012 that's going to ignored...Time to close speciality training

A friend of mine, Dave Fiorella, published one of the most widely read paper in the radiology literature this year.  

Should neurointerventional fellowship training be suspended indefinitely? -- Fiorella et al. 4 (5): 315 -- Journal of NeuroInterventional Surgery

He argues that the world has enough of his own subspecialty, neuro interventional surgery (NIS), and that training programs should voluntarily close.  You may not have heard of NIS.  These physicians care for a small group of patients that typically need blood vessels in their brain opened or closed.  Examples include stroke patients (blocked vessels need to be opened) and aneurysms (diseased vessels need to be closed). People like Dave do their work by running a small tube, a catheter, from the groin up to the head and then inject things through these tubes to open or close the vessels-pretty cool stuff!  and a huge advance from 25 years ago.  Before NIS, neurosurgeons would open your skull, do their work, and close you up.  And now, Dave says we have enough.  Why?

After training (which included NIS) my first job was at a good, but smaller community hospital outside Seattle.  In part, I was hired to build a stroke program and grow neurosurgical services.  However, these skills require constant practice, and 6 months at this hospital I had only done a handful of cases.  As far as the professional requirements were concerned, I was competent to do these procedures.  However, deep down I wasn't so sure. Within 18 months I gave up doing these procedures, preferring to send patients to the university up the street.  

A coiled aneurysm.  The big ball is the aneurysm.  
Imagine pushing a wire into a basketball, replacing air  with wire.

My experience is similar to many physicians.  There simple aren't enough patients needing high end procedures to go around.  As a result, skills and quality suffer.  Unfortunately, hospitals want to compete.  Every center wants to be a stroke center or a chest pain center, a (you fill in) center of excellence.  In part this is done for branding, in part this is done for contracting.  Insurers want to simplify the process and get all the services they need from a few hospital partners.  The big loser here is the patient.  Many studies have documented a relationship between volume and outcomes (https://leapfroghospitalsurvey.org/web/wp-content/uploads/2012/03/Fact_Sheet_EBHR.pdf).

You or a loved one may need these services.  A physician will come to talk to you about the risks (you could die), benefits (the procedure may help you), and options (they hopefully mention other treatment alternatives, but they may not mention that you can go down the street to another facility).  Your outcome will be tied to the experience and volume the physician has done.

If there were fewer NIS physicians, there would be more cases/practitioner and better outcomes.  But the likelihood of programs are going to voluntarily shut down- that's not going to happen as long as hospitals are hiring.  There is a way out of this dilemma.

At the consumer level, you should ask the hard questions.  Doctor, how many of these have you done of these, when was the last time you did one of these?  Is there anyone else who has done more of these procedures in a 20 mile radius?  At the payer level, there should be a a requirement for a certain experience before paying a provider, and then there should be recertification, a certain number of on going cases to keep getting paid.  Ultimately, the payer should ask for outcomes from the provider, information about how their patients are doing 3, 6 and 12 months after the procedure.  

In short, Dave is right.  Practice makes perfect.  There just needs to be a business model supporting the desired (patient) outcome.

Why I use LinkedIn, and hope you do too....in the New Year, build your "hubness"

I am a Jew married to a Catholic.  Neither of us practice.  Next year we'll be married 25 years.  We have 3 children, all whom I am proud to call a friend.  But, I have this nagging feeling.  At the end, I'll get to the gate and be brought before (Jesus, Budda, Mohammed) who will ask why am I deserving.  Or at a minimum, with my last breath, I want to reflect on a life well lived.  That's why today I use LinkedIn.  Most people look at Linkedin and see a job board on the web or a professional Facebook.  I see something else: an accelerator of human potential.

Several years ago I read Malcolm Gladwell's Tipping Point.  He talks about the spread of ideas and how if you are lucky enough to meet a hub, the chance of your idea spreading to the next person, the right person, goes up exponentially.  At that moment, I realized that I wasn't getting any faster, or better looking and that senility was fast approaching. Though in spite of this inevitability, I knew that I could actively pursue my "hubness"… that I could become a connector.  When I met new connections I could learn about these people, what they were interested in, what they aspired to do, and file that information away until the day when I met their puzzle piece, the person who completed them.  Together, the two people could go on to accelerate human potential.

Fast forward to 2003: along comes Linkedin.  I had found the perfect tool.  Ii told me what people were doing, what they cared about, and when they changed paths.  It is the perfect tool for finding the missing puzzle pieces.

If you look at your world there are probably 20 people you see on a daily basis.  There is another 100 whom you like, respect and perhaps see every other year.  The is a larger circle beyond that, with some affiliation, but perhaps they have particular skills or knowledge.  With LinkedIn these secondary and tertiary circles become your world.

Today, I may spend as much time collaborating with people in my network as I do with people in my building.  I actively go through my network once a month, introducing people in my network simply because they should know each other.  Their pieces may fit, they may not, but I hope the world is a better place because of it. Of course in all honesty, I am the big winner.  I hear about interesting things people do, and sometimes join in the projects I helped catalyze.

Just imagine if each of us made it a New Year's resolution to build our “hubness”; to look for ways to bring strangers together so that they might call each other a colleague.  LinkedIn, or at least the process it enables, is one of the most powerful tools we have...we just need to use it correctly.

Shoe boxes should be for shoes, not medical records

If you ask a person coping with a chronic illness for their medical records, they may take out a shoebox with a neatly organized papers and CDs.  They hope the next doctor or nurse will open the box, look inside and help them.  This almost never happens.

What's in your box?

There is simply no time for providers to put this information into a meaningful story.  The provider tends to reorder labs, and begin from scratch.  

Patients and providers agree this is absurd.  Records should be immediately at the time of care.  This would enable better, more cost effective care.  Industry has spent decades trying to solve this problem, but it is a work in progress.

Centralized versus decentralized records.

In part, this failure reflects American healthcare's focus on the doctor and the hospital rather than the patient.  There is an expectation that others will care for us, rather than engage us.  Medical record solutions tend to pass centrally from patient, to doctor, to EMR, to a central clearing house (sometimes called an health information exchange, HIE).  

HIE, centralized healthcare records

HIEs sound like a great idea.  If the patient goes to 2 facilities or 2 different doctors, records would magically be collected and viewable by all participating facilities.  Unfortunately, HIEs are more concept than reality.  HIEs require high level collaboration from competing healthcare systems.  Further, there is first adopter risk.   Imagine buying the first fax- who would you send to? 

An alternative solution would centered around the patient.  In this case, the patient acts to collect data about themselves.  But rather than the shoe box, the information is organized so that others use it effectively. 

Google and Microsoft in fact took this approach and spent billions to create PHRs- this has largely been a failed effort  

Google Health shut down after several years

The medical apps industry is another approach.  Apps allow the people to collect all sorts of data about themselves (weight, blood pressure, physical activity) People can look at the information themselves or  present it to their practitioner.  As yet, industry has not achieve significant adoption or investor value.  

Both apps and PHR currently reach the wrong market. Apps and PHR tend to be used by the "super fit," the people trying to obtain that last little bit of potential immortality.  Although the super fit are a market, they are not the market insurers and providers are trying to reach.  The people who need PHR and apps, the sick, tend not to use them.  These people are typically older and less tech savvy, they tend to be less focused on their "wellness."  

Portal or PHR?

Hospitals are currently implementing portals, web based tools for patients and providers to see medical records. Healthcare systems view portal as an evolving service expectation, a chance to build customer loyalty.  However, this strategy is limited.  Portal is an extension of the hospital EMR.  Current portals do not aggregate records across the continuum or enable the patient to collect information about themselves.  

Would it be better if hospitals provided PHR?  This could be a card given to patients leading all providers, those from the hospital and their competitors, a web site where they could view and enter enter information for the patient.  Rather than centralize the information via an exchange, this would decentralize efforts around the patient.  At a minimum, this would allow providers to note that the patient received care and there are records to share.  Better would be an upload of records to the PHR; this is already possible via an accepted standard (CCD).  This would not replace EMR (which provide necessary documentation, scheduling and billing) but instead supplement care documentation.

Decentralized, Collaborative PHR records could supplement EMRs.
Providers across the continuum  could add to the record for the patient.
Most PHR ask the patient to do all the work currently

Compassionate Capitalism- towards a sustainable business model for collaborative healthcare records 

As mentioned earlier, centralized health exchanges, with a centralized business models, have largely failed.  The return on investment ratio for the early adopters has not enabled wide spread adoption.  However, decentralizing the offering may have unique benefits for a healthcare system.  Registration in a system showing patients their hospital records, occurrences or records from other providers  as well as chance to record their own observations is value, something patients can't get or can't maintain (eg...the Microsoft and Google offerings) on their own.  Building brand through patient value equates to loyalty. Further, collaboration across the continuum, provides the necessary infrastructure for value based  cost effective care delivery.  This is not rocket science, but rather a repurposing of existing market tools.

Best Wishes for the New Year

The National Rural Health Resource Center wishes you a happy and healthy season and all the very best in 2013!

We look forward to working with you in the new year!