Just Do It! ...Works for Shoes, But for Healthcare, Not So Much… Have a Plan & Look Before You Leap

I am fortunate to not only practice medicine and train physicians for the future.  However, jobs in my field (radiology) have become scare.  One of my residents return from a trip after meeting with a group in his home state.  He mentioned to me the secret to the group’s success- Just Do It. Like billions of others, I’ve heard with Nike’s slogan. In the context of shoes, it’s a motivator to do the right thing, to get off the couch and get active.  However, for doctor’s, just do it may not be such a good mantra.  It is often the easy way out, better for the them, but potentially not for the patient.  

As radiologist. other physicians ask for things while caring for patients.  They might need anything from a chest X-ray up through a biopsy.  When another doctor asks for something, most radiologists learn to just do it.  They have learned that their customer, in this case the referring doctor, is always right.  

From personal experience I can tell you that to not just do it, but rather to engage in a conversation about the exam’s value may be …less than pleasant.  Often the patient sent for the exam is in front of me.  I can’t reach their doctor.  I have to explain why we might delay the test and go another way.  This discussion may take twice as long as the actually completing the exam, the patient’s confidence may be shaken and at times they’re upset.  However, I try to think what would I want for my family.   As a specialist, I may know more imaging options, the risks and benefits  and other options of the “ordered” procedure than the referring provider.  

This scenario is not limited to radiology.  The medical merry go round of pain has similarities.  The patient comes in to see the doctor expecting something to be done.  The simplest thing for the doctor is …just do it, write a prescription for narcotics, and get on to the next patient.   This starts a sad cascade of care often ending in addiction.

There are personal & financial incentives driving the just do it healthcare cultural.  Physicians would tell you they’ve never heard of someone getting sued for getting an imaging study or a biopsy- why should they take the personal risk of not just doing it?  And the reimbursement for just “not” doing- isn’t very good.  As eloquently illustrated in the Healing of America by TR Reid, healthcare around the world often reflects the countries cultural.  We see ourselves as doers.  Our incentives via reimbursement, are reflected in our care bias.

Can anything be done to combat the pressure to just do it?  I have a simple suggestion- have a plan. Every decision, every test in medicine, should have a next step.  Before anything is ordered, there should be a question..what next?  As a patient, ask what we (patient and provider as a team) will do next based on the result?  If the answer is nothing different, perhaps the first step should be skipped?  If you’re not going to have back surgery, regardless of the imaging, perhaps you shouldn’t be image.  If you start on narcotics for pain, when are you stopping? What else are is being done to diagnosis and treat the pain.  Even when the result is negative, this should be part of a plan. A negative test (eg…there is no evidence of cancer on your CT) can be the most liberating of all- what next?  Whenever possible, patients should ask for a plan- tell me the steps we are going to take.  Providers should have a plan- how does step 1 influence step 2?  And payers should require a plan before reimbursing.

For selling shoes, Just Do It offers encouragement.  For care, just do it seems more a cope out than good practice.

Death by Data- How Healthcare Providers Went from Historians to Librarians

Thirty years ago, in what might be referred to as BPC (before the personal computer), I took a class asking whether technology made our lives better or worse.  The topic seemed absurd, but it fulfilled a graduation requirement.  The professor from Bell Labs was part techie, part philosopher.  By the end of the semester I didn’t throw away my Walkman, but I also thought the question had merit.  Then I went off to med school and, for the most part, was able to forget about technology- everything was on paper. 

In medical school I learned to review the medical records (huge binders often marked by roman numerals designating volumes related to a patient) and to take a history.  Listen and the patient will tell you the answer was the mantra.  The patient’s problem was a narrative, a story of what happened to them in the past, and how it might have contributed to the present.  The treatment plan was the hoped for future.  Ideally, this all fit into a story that made sense.

Towards the end of my residency, electronic medical records(EMRs) began to appear.  This made sense.  Huge paper binders were difficult to review for a patient and essentially impossible for clinical studies.  However, EMRs were not built to tell a story but rather enter data.  The earliest EMRs were more for collections (revenue cycle) rather than care.  The narrative, the patient’s story was almost an afterthought.

Most of us are familiar with the clinical result.  Providers often has their eyes on the screen rather than on the patient.  Even if the right questions are asked, the information gathered fills tiny boxes, more like books in a library, rather than constructing a story.

Recently Melissa McCormack, a medical researcher at Software Advice, blogged (http://thehealthcareblog.com/blog/2014/01/06/actually-wed-all-be-better-off-with-our-health-records-on-facebook/) asking why medical records couldn’t be more like Facebook, an information timeline (note, she was not suggesting FB become a medical record, but rather EMRs borrow from the structure of FB).  I agree.  Current tools gather data with no real consideration of purpose, of constructing the patient’s narrative.  Stories can be told.  FB has shown it’s possible.  The medical community just needs to think different.

In Greek Mythology curiosity gets the better of Pandora. She opens a box she’s warned not to.  In doing so, bad things fly out- war, disease, envy, etc…She quickly closes it, but it’s too late.  When she opens it again, only thing left in the box is hope.  The question raised by my professor decades ago is truly academic. There is no going back.   We can’t live with technology.  However, technology needs a governor, a brake that ties it back to the problems it is designed to solve.  Data for data’s sake may not make our lives better.  Without constantly considering people and process, we run the risk of making things worse rather than better.  Nothing against librarians, but I would prefer to go back to being a historian.

The Importance of Developing a Marketing Plan for Your Hospital

By Sally Trnka, Director of Network Development, Western Healthcare Alliance

This spring I took a two-week vacation in Western Europe that proved to be an incredible experience.  A major contributor to the success of the trip, and my personal level of enjoyment throughout, was the hours of work that went into planning a 15-day European vacation. With a set amount of time and resources, it was critical that I spend time looking at maps, exploring travel routes, reading hotel and restaurant reviews, talking with people who had traveled there before, and determining timing and costs of different sites. All of my different ideas had logistical and financial price tags that needed to be strategically weighed against what I was hoping to achieve. I didn’t want to waste resources (time or money) so I needed a map; I needed a plan. The same is true for your hospital and your marketing efforts—you can’t be cavalier about them so you need a plan!

I’ve heard a host of reasons as to why rural hospitals don’t have the time or the resources to allocate to the development and implementation of a strategic marketing plan (“Resources are being used to fulfill regulatory requirements,” “We have a negative bottom line,” “We don’t have skilled marketing professionals”).  While all of them are legitimate concerns, they are not sufficient rationale to put your marketing efforts on the back-burner. 

Many rural communities are hemorrhaging patients that are flocking to the larger, urban centers to receive specialized care or care they perceive to be of higher quality. A large part of that is simply that patients are unaware of the depth and breadth of services that are available to them in their own community, particularly outpatient services that rural hospitals are going to need to maximize under the new reimbursement model.  The National Rural Health Resource Center  (The Center) has been conducting Community Health Needs Assessments for more than a decade across the country and we continually hear that patients are woefully under-informed about the care they care receive in their community—frequently at lower costs and higher quality.

Spending the time, energy, and financial resources can help you to educate people in your service area about the scope of care they can receive at your facility. A Strategic Marketing Plan will help you to set more effective priorities, better allocate resources, assess efforts and accountability, identify areas for improvement, and articulate the value you provide to your customers.  A Strategic Marketing Plan also allows for information and knowledge to become institutional and aligns all of your efforts across departments.

The Center offers comprehensive Community Health Needs Assessment and Marketing Planning services that can help support your hospital, or rural health network, assess community needs and perception, and develop a comprehensive marketing plan to support outreach efforts to your community. See the website or contact The Center's Community Specialist, Kami Norland, for more information. Remember, in order to maximize resources and experience, you need to plan!

Healthcare Technology Should Be about Enabling, Not Replacing, People- why it's less about the app and more about the process.

My friend Lisa Suennen recently wrote a thoughtful review of the Computer Electronic Show (#CES) http://www.venturevalkyrie.com/2014/01/11/people-who-need-people-a-ces-follow-up-report/5961.  For those of you unfamiliar with the event, there were more than 2 million square feet of exhibits and roughly 150,000 people last week in Las Vegas.  Digital Health is part of a broader offering covering all things tech.  Amongst all these glittering objects, the of envy for any true geek, Lisa had several interesting observations.  First, that many health entrepreneurs are (as she notes, wrongly) looking for ways technology can replace people, rather than enable people.  There is a general sense that scale (a magic word for the investment community) requires fewer bodies.  Second in her opinion, the ultimate goal should be a mash up, a convergence of IT, devices and services for true value.  I couldn’t agree more.

My efforts focus on collaboration.  Within health IT is what seems obsession with data, EMR’s and dashboards, but for me the future is about teams- getting the right people at the right time to come together.  Without this opportunity for timely expertise and collaboration, the value of data decays.  Information has trouble converting to knowledge.  However, collaboration is messy.  It requires thoughtful consider of how people and process interact with technology.

Replacing the Pager with a PDA.

For decades the pager has been the official form for medical communication.  It is safe and secure.  It is also limited, inflexible and a poor choice for collaboration.  In response, many physicians have adopted texting as an alternative method of communication.  However, as of September 2013, new federal mandates limit texting.  There is a potential 50,000 penalty for texting a single instance of patient information being exposed in an standard text.  The response by many vendors has been ….I have an app for that, to wrap messages in a secure technology.  However, an effective solution needs to be far more nuanced.

In the consumer space, apps can go viral.  However, the social fabric and supporting infrastructure for healthcare presents a number of obstacles.  There is an assumption that all providers will have a PDA.  However, PDAs at work are expressly forbidden by many nursing regulations.  This means messaging must be cross platform.  What if an individual doesn’t want their PDA to be leverage for work responsibilities; is the hospital required to provide a device?  Many hospitals do not have have the necessary wireless/cellular infrastructure to support PDAs.  Most hospitals do not have accurate information on their providers beyond pager numbers and an office address; snail mail remains the de facto form of communication.  

For their part, physicians often do not want to be reach directly.  In part this is a workflow issue.  Imagine a physician is in surgery and receives a call telling a patient needs their attention immediately.  Do they leave the surgery, or stop the surgery and call someone to cover?  There are reasons for call centers.  Practically, there needs to be permissions set by time of day, availability and role for the collaborative communication to be appropriately routed.  This requires high level enrollment into a “service” identifying roles and managing preferences.

The result has been islands of communication.  Groups have adopted apps for internal communication but no real holistic community of providers for collaboration. With the help of a vendor (disclosure- I have invested in the company, #Emerge.MD), St. Joseph’s has deployed a technology enabled service helping people to collaborate.  This service enables provider collaboration by name (eg...Dr. Jones) or by role (neurosurgeon on call).  It incorporates nursing requirements (for desktop messaging) as well as physician preferences.  Via this service teams of people can be brought together text, voice or video.  Importantly, there is sponsorship from a business owner, the hospital and more broadly the Accountable Care Organization.  The executives have something to gain- more cost effective care (throughput issues, access to specialists, etc…). This solution is now spreading through Dignity Healthcare. However, this was not plug and play.  It required extensive knowledge about the people and process rather than strictly technology.   

Even replacing an archaic device, the pager, with a PDA is not about technology but rather about understanding and management of a constellation of social processes. At the end of the day, health and healthcare are personal.  There are many processes that can be automated and improved upon via technology.  But for my money, I am with Lisa.  Transformation will be more about enabling rather than replacing people.   And people require services, not technology.

The Doctor is Always Right- Except When They're Not- Bias, Myth and Paternalism in Medical Decisions

A friend of mine was kind enough to drive his 85 yo mother to get a colonoscopy.  She had a normal study 18 months before.  There was some evidence of minor bleeding & her doctor just wanted to be sure.  This meant the "prep," with instructions to drink the last bit at 3 am, followed by a trip to the doctor's office at 530 am.  Another friend was told they had melanoma.  As you might imagine, this caused concern.  The doctor recommended a biopsy followed by 2 additional surgeries.  When I asked what stage melanoma, I was told it was stage zero; in terms of danger, this is just above freckle, the lowest potential for growth.

Both examples represent common medical experiences. In each case, there was an alternative- do nothing. For the older woman, it was reasonable to ask what the doctor expected to find and, if bad, what would be done about it.  I personally want to die with an undiagnosed cancer.  In the second example, surgery for the “near benign” required pain, risk and expense.  If removing the lesion via biopsy gave a 98.5% chance of not getting the disease, were the 2 surgeries worth the incremental improvements?

Each situation gets to the heart of "consent."  Ideally every procedure offers the patient a real choice.  After explaining the risks, benefits and alternatives, the patient chooses to proceed.  However this is rarely done.   Bias, myth and, on some level, well meaning paternalism all play a role.  

Bias- Mental tendency or inclination, especially an irrational preference or prejudice

Imagine spending 20 years learning a trade.  It is natural to believe you are helping, not hurting.  Physician's believe in their art. To expect all options are equally considered, goes against human nature.

Myth- a widely held but false belief or idea.

Although medicine is shrouded in science, we often do what we do because we do them. Practice is passed on from generation to generation. Many things are taken as "truths," without any real justification.  A recent Mayo Clinic Proceedings reviewed reversal of a 146 contradicted medical practice (MCP, August 2013). Medical knowledge is purported to be based in science but in actuality, this often not the case.

Paternalism- Though I walk through the shadow of death, ...thou art with me, thy rod and staff to comfort me. Psalm 23:4

Rod of a healer

It is difficult for both providers and patients to have a conversations as equals.  For the patient fear and anxiety go hand and hand with illness.   This is overlooked by those thinking computers will replace providers in the near future.  Most patients do not want to make life threatening decisions alone.

Providers may feel pressed for time and a responsibility to act as a filter for their patients, leading them to the right choice.  Unfortunately, well meaning desire can often result in an unbalanced discussion.  

In Seinfeld, Elaine was blacklisted as a bad patient.

I should note that most providers are not consciously motivated by financial gain.  Yes, treatment results in payment, but the vast majority of people believe that they are offering the best option.

What to do…Ask- what are you getting for the risk, what is the downside to waiting?

With all these well meaning forces, I would suggest a relatively simple approach of asking and when possible, consider watchful waiting.  For many patients, asking is intimidating.  There is a fear asking will degrade the relationship.  Most physicians are willing to explain there reasoning; and if they won’t, get a second opinion. Definitive answers are not always the best answers.  Finally, ask the harm in waiting.   Avoiding risk today may be better than possible risk tomorrow.

HIT Implementation Challenges for Rural: Follow the bouncing ball!

Joe Wivoda, Chief Information Officer
Transforming any industry is challenging. Health care is going through a multidimensional transformation right now: Reimbursement changes from volume to value, increased focus on quality, and implementation of IT systems and meaningful use. Every hospital, clinic, skilled nursing facility, and indeed all health care providers are coping with these changes. Rural facilities share many of the same challenges as their urban counterparts, but there are some that are uniquely rural.

Providing patients with timely access to their health information, and getting sufficient numbers of them to view, download, or transmit their data, is a challenging meaningful use requirement. This is much less of a technological challenge, more of a marketing and patient engagement challenge. In a rural hospital or clinic, implementation of the patient portal can be challenging due to the lack of IT resources, and HIT vendors that focus on rural are often too busy to implement the portals early enough to build a patient engagement campaign. It takes time to engage patients and get them setup to log in to access their health information and it is important that rural providers engage their community as a whole. Discussing the benefits of online access to your health information on the radio and at public events will go a long way to get patients excited about being more involved in their care. Rural has a significant advantage here, primarily because they are so close to the community.

Participating in health information exchange, particularly state-based exchange, has been frustrating. Technological changes, unsustainable business models, and low adoption levels have kept state HIEs struggling. In addition, many HIEs have focused their efforts on capturing the urban hospitals and integrated delivery networks first, essentially putting rural on the back burner. Query-based HIE, as opposed to Direct Secure Messaging, is difficult to implement. Exchange is so important for Stage 2 of meaningful use, and for high quality and safe patient care, that it can not be ignored. Rural providers should look to Direct for being able to exchange with their referral partners while working with their local HIE for future query-based exchange.

Rural clinics and hospitals that do not have a culture of process improvement are at a significant disadvantage when implementing an EHR. All too often I visit rural facilities that have no established process improvement program. Based on my experience, this is the single most important thing to have when implementing an EHR. Without PI you will implement an EHR in a way that will likely decrease productivity, or worse, decrease patient safety. The EHR is not built with idealized processes "baked in", you need to do the work. Understand how you do things today, understand how the EHR works, design a new process. We like Lean as a methodology, but PDCA or others are valuable. Rural facilities, who are usually stretched for resources and have staff wearing many hats, need to make PI a core part of the culture. Urban hospitals and IDNs have been doing this for years, and CAHs that have embraced PI have been shown to be financially sound and their EHR implementations go much better with less fixing after the go live.

Rural has the ability to move quickly. These are challenges that can be overcome. Continuous process improvement, workflow analysis and redesign, should be central to not just the EHR implementation (or improvement) but to the operations as a whole. HIE, patient engagement, and improved utilization and efficiency from the EHR will follow once good process improvement activities are made central to the work.

What do you think are HIT implementation challenges in rural?

Congrats, You've won a shopping spree. Unfortunately, the stores are closing. Why you should worry about Medicare instead of Obamacare

After 30 years in healthcare, a someone finally explained Medicare to me.  Here is the short version. There are 4 parts (A,B,C, & D).  At 65 most Americans get parts A and B.  Part D is for drugs; the senior can be responsible for several thousand dollars/year.  Part C is the interesting one.  

"C" coverages lab, X-ray, hospitalizations, doctor visits, emergency transport- most things commonly thought of as healthcare.  You can choose to keep Part C which is free in most geographies or add a supplement reducing or eliminating co-pays.  Most seniors choose supplement plan "F."  For another $130/month (with the required $104 for Part B this brings the total to $235/month), the senior has access to any primary doctor or specialist, any hospital network accepting Medicare with no additional charges.  This is fantastic coverage.  I pay almost 10 times this amount and still have a deductible.  This is like a an unlimited shopping spree for a buck.  But unfortunately, many of the "healthcare" stores may be closing.

Here is the problem.  The healthcare costs a of money a lot more than $235/month.  The government has 2 choices.  Additional revenue could be raised, effectively charging seniors more for similar coverage.  This is DOA. Politicians like being politicians.  They, like most of us, think of themselves first.  Reducing entitlements, particularly Medicare, is suicide.  Alternatively, expenditures could be reduced.  This is what has been happening.  Hospitals, doctors, device manufacturers, labs, etc... are all being paid less.  

Although a popular public option, this may not be a good long term strategy.  Yes, the healthcare industry is bloated and mismanaged, but inefficiencies are not going to disappear easily.  As prices fall, businesses are going to fold- fewer hospitals, fewer doctors, less innovation.  I am not suggesting healthcare will disappear, but rather access will decline.  Like in any business without profit, store shelves become bare.  Politicians will keep their jobs.  Entitlements will be left untouched, but simply worth less. 

This has a ripple effect.  With all the dialogue around Obamacare (ACA as it is now again being called), it is easy forget the vast majority of expenditures are for the elderly.  Medicare is untouched.  If reimbursement for Medicare results in fewer choices and less access for the elderly, this will directly affect those participating in Obamacare; it's the same delivery system.

The ACA presumes all Americans need to pay for healthcare.  Although there is (bizarrely) not general agreement on this point, most believe a civilized society requires roads, schools and police, & care for the sick.  However, by segmenting the population into 2 groups (pay as you go for <65, and pay once for all you can eat for >65) seems destine to fail.  Ultimately every group must have some skin in the game when making medical decisions.  I am not suggesting the elderly should bear the full cost of their care but rather that price for care should be part of the decision.  When the doctor suggests a course of action, price should be at least part of the conversation.

Forget Obamacare.  It's a fly on the elephant's back.  American's have much bigger problems.  We need leaders who argue for what's right for the country, not for their careers.  We need lobbyists (yes, you AARP) who recognize that saving money for their members today may mean fewer services tomorrow.  People of all ages should pay something for more care.  This is the only way to actively engage the consumer in the decision process.