Boston: Coincidences, Complexity, Continuity, Care

By Cyndy Nayer, April 25, 2013

America's Freedoms Are Our Vulnerabilities

There is no doubt that the terrorism of the Boston Marathon 2013 was heart-stopping, heart-rending, and a cruel reminder that America's freedoms are also our vulnerabilities.  It's also a bit ironic that, because of a family emergency, both of my daughters had flown down to our house and were with us when the bombs went off.  Why is this important enough for me to mention here?  Because if my older daughter hadn't come down to help, she would have been exactly at the finish line where the bomb went off. Coincidence?

I don't believe in coincidences.

The week, and the socialmediasphere, have been resplendent with coincidences, the most poignant of which was the story of the couple who both were in the health care provider space, both came to cheer the runners of the marathon, both had a portion of their left legs blown off in the explosion.  They were separated by the blast, and they remain separated in different hospitals, but they are recovering and they are talking by phone to each other (see below for how you can help).

Who were the terrorists, what was their motivation, what will happen to the survivor, I have to leave to the sleuths and judicial systems to discover and decide.  My work is to uncover the learnings that we can all ingest to fortify our health promotion and business recovery.  Here are some thoughts.

1.  Boston has terrific hospitals, prepared for trauma management.  I've managed many fitness events, and, of course, a key component was the clinical staff onsite.  They volunteered their time for running injuries, dehydration, and the sort.  Some of them on April 15 had seen combat duty in Afghanistan and Iraq, and they were able to flip into mash-unit mode quickly.  All of the injured who made it to the hospitals have survived, albeit many have much rehabilitation to work through.

2.  Boston has moxie and motivation.  Bostonions have been described recently as gritty, defiant, and strong, and this makes great sense since this is the birthplace of the American Revolution--the shot heard round the world--and of the freedoms that would coalesce into the US Constitution.  When the explosions came, the runners ran INTO the crowds to help those who were hurt, ran to the hospitals to give blood (another 2.5 miles after their 26.2 mile run), and reached out to one another.  They may fight like family, but when the pressure is on, Boston is one big supportive family. For more on the grittiness of Bostonians, and a chuckle, click here to see Colbert's Report for April 16, one day after the bombs.  

3.  Boston finishes what it starts. Samuel Adams (not the beer, but the revolutionary) said, “Nil desperandum, Never Despair. That is a motto for you and me. All are not dead; and where there is a spark of patriotic fire, we will rekindle it.” There were people around the nation, and now, around the world (London) running races for Boston over the past 10 days, and there will be more.  There are calls for boosting the economy and taking Boylston Street back--it opened today--and for helping those who were locked out of their homes and businesses for these days.  This is the Boston that warned of the Red Coats, rode the Freedom Trail, waited 86 years for the Red Sox pennant.  When folks were hurt, people did what they could:  one woman baked oatmeal chocolate chip cookies for the police/troopers/FBI/ATF, etc. to eat when the 2nd suspect was arrested.  Grit and defiance demand food, too, after all.

4.  Boston wears its patriotism and small-town love proudly.    Read this excerpt from one of the London marathoners, who also ran in Boston:

“I had a hard day out here,” said Neynens, who wore a 2013 Boston Marathon hat during his London run and finished in 2:48:09. “I was hurting, but obviously I was not hurting near as much as the injuries that I saw, people who lost their legs. I finished for all those people who were hurt and those people who couldn’t finish last Monday...

There was a banner we passed around Mile 25 that said, ‘Run if you can. Walk if you must. But finish for Boston.’ That meant a lot to everybody. It was great to see the support of everybody out there for the runners and for Boston."

 There were lessons for health, healthcare, and healthcare reform, too.

1.  Interoperability of electronic medical records could have been a problem.  In the marathon were runners and family-watchers from around the world.  What if there were a diabetic runner who, because of the bombings, was delayed in his/her sugar control?  There are so many other "what ifs" that the message is clear:  we need to quickly find a way to make these EMR-EHR-PHR talk to one another for the safety and security of the providers, patients, and communities.  We cannot afford to waste time finding a knowledgeable relative when life hangs in the balance.  [I wrote about this lack of interoperability in my post "EHR Is Speechless"].  There is no magic about data, the rules engines can be preserved as proprietary to each company, but the data must be accessible.

2.  Teamwork. Who will ever forget the masses of security forces closing in on the final suspect?  Or the video of the Chief of Police of Watertown MA saying his troops were never trained on counterterrorism, so they just did what was they thought was right?    Those of us riveted to the scenes will remember the ATF, FBI, fire departments, EMT, Boston police, State Troopers, and so many more.  But how many noticed that hot food was brought by the NY-NJ Port Authorities?  How many could ever forget the cheers and singing and clapping by the Watertown citizens when the ambulances and security cars crept slowly back into the city?  Now, imagine those kinds of teamwork in communities of care, with warm "handoffs" from primary care (Watertown police) to specialists (BPD, ATF, FBI, MA troopers) to recovery and long-term care (Red Cross, Boston Globe, and so many other watch-dogs and care providers).  Everyone had their job and new exactly what they had to do.

3.  Continuity and safety.  Recently I saved an article on the rates of hospital infections in the US compared globally, sent to me from my colleagues at MCOL.com.  Because of the trauma training, the warm handoffs, and the sense of accountability, continuity is a given in Boston.  It's the accountability that will guard the injured, the fallen and the recovery.  There's a new sense of "we share in this," and it's this sense that carry Boston through.  That's the real message of accountability:  we all own at least a portion of the problem, whether it's economic recovery or health promotion, and we all have a responsibility to step up to manage our community better.

Of course, in the land of the Red Sox, with the frame of David Ortiz' opening moments in Fenway Park, and the surprise visit from Neil Diamond to lead Sweet Caroline, the poignant moments caused tears and love and hugs.  For us who weren't in Fenway, or Boston, or Watertown, I treasure the picture that went viral on twitter and other social outlets:

 I don't think there are any coincidences.  I abhor terror, bloodshed, violence.  But these moments that I've called out remind me, and I hope all of us, of the goodness of people.  Who could possibly convey it better than Fred Rogers?  We needed to hear his words, "Look for the helpers," right then, right at that moment.  It opened our hearts and made us feel safe again, and we spotted more helpers and lavished praise, because we all needed to heal.

And then Boston Daughter (who had returned to Boston) sent me an email and a picture that she took, the one that starts this blog post, the site that amazed and tore and then opened her heart.  She told me she couldn't sleep, walked to the memorial Monday morning at 5am to pay her respects, and left her pink running shoes because she wanted to be part of the healing, too.

If you want to be one of the helpers, here are two ideas for you for donations.  There are many more, I simply had intersections with each of these here:

If you, like me and my Boston daughter, are an avid fitness participant, then you may want to make a purchase at @unitedwestride UnitedWeStride will donate all the proceeds from the purchase AND AN ADDITIONAL DOLLAR

@JetBlue  I audaciously sent a tweet on 4.22 to @JetBlue asking for serious discounts to Boston so we could boost the economy--I'm betting others did, too. On 4.23 I received an email with serious discounts.  Help those most affected by the Boston tragedy through The One Fund Boston, and JetBlue will match up to $100K. http://www.jetbluegives.org

 I hope peace comes to those who mourn and to those who heal.  I hope strength comes to our leaders and our protectors.  I hope our communities come together for health.

Getting Healthy

By Cyndy Nayer, April 1, 2013

In January 2013, US News published a report on why Americans aren’t healthier and gave us the concept of a health lag.  In fact, the gap between America’s health status and that of other industrialized nations is a 30-year trajectory of lower outcomes.

Last week, Modern Healthcare published a review of Kaiser Family Foundation findings in which the highest hospital readmissions were directly correlated to the unhealthiest counties in the US.

On the same day as the MH-KFF release, I was privileged to receive a tweet on patient engagement that highlighted the blog of Gilles Frydman  on PatientDriven.org, which highlights the real engagement and outcomes of patients who seek to understand their conditions and treatment by conversing with others.  The point here is in the definition of engagement, per the blog, “An engaged patient is someone deeply involved in the scientific understanding of their disease, fully aware at all times of the entire spectrum of available therapeutic options. It requires a set of learning, cognitive and psycho-social tools that can only be acquired by conversing often with a real network of peers who are similarly involved in this complex endeavor.“ 

This, says the author, is exactly opposite of the current definition of patient engagement as used by HIT, care professionals, benefits personnel, and service providers:  “the engagement flows from the various professional stakeholders of the health care system to the patients. It is a direct extension of the concept of consumer engagement.”

It’s exactly the discussion I am most involved in, most of the time, in which the (choose one) doctor/ IT developer/ hospital administrator/ national thought leader talks about patient engagement as the patient behaving according to the “guidance” he/she is provided.  But what if the guidance reaches the patient at the same time she is dealing with her teenager who had a car accident, or her husband who may lose his job? What if the “guidance” is a follow-up visit or test, but the office isn’t open late when she is off work? What if the “guidance” is the purchase of a pharmaceutical that she either can’t afford or that may cause side effects for her?  What if she simply didn’t understand the instructions or, three months later, is feeling better and stops the medication or falls off her nutrition plan?

Unfortunately, the problem here is that the engagement and persistence (which, by definition is part of engagement) did not occur because people have other parts to their lives than the body parts with issues.  They have financial needs, emotional needs, social needs, even transportation needs that interfere with engagement. While the most-influential people in the patient’s life, according to surveys, is the clinical “face” (doctors, pharmacists, nurses, etc.), these people do not follow the patient everywhere, and others in her sphere of influence take precedence.

Emergency department visits drop when medical practices extend hours. There are examples of patient engagement strategies that work and that translate directly to saved dollars.  In surveying more than 9,500 people with steady sources of care, the Center for Studying Health System Change focused its results on 1,470 individuals who had tried to contact their primary care practices after normal business hours in the past year. The study, published online in Health Affairs on Dec. 12, found that nearly 21% had difficulties reaching their physicians after hours, and those who reported more difficulty accessing after hours had higher rates of emergency department use (37.7%  and higher rates of unmet medical needs (13.7%).

As I’m on my relentless pursuit of solutions that deliver better health outcomes, I have to  emphasize this, re-emphasize it, and then state it many times more.  Those who doubted the power of value-based benefit design or outcomes-based clauses did not fully understand the suite of services and, what I call surround-sound messaging, that is necessary for patient engagement in health.

We cannot be paternalistic, nor maternalistic, in making health the end goal.  We have to meet people where they are and stop treating body parts separately (you know, hypertension over there and depression over here and diabetes…).  We have not only organize in patient-centric efforts but, perhaps more importantly, in patient-driven circles.  This is the success of the senior-citizen breakfasts that promote Medicare health plans, of the breast-health discussions that occur in churches and hair salons, and of the Dr. Oz and Dr. Phils of the world who reach through social media (including TV) to their audiences.

Transparency will only matter if the patient is seeking healthcare.  If, instead, she is seeking a carpool for her kids or the money for rent, then transparency of treatments may not be as meaningful, if it’s on the radar at all.  ”Entitlement programs,” as Medicare and Medicaid are increasing called, cause splits in peer groups and often in the same family, pitting seniors against young working adults in the “subsidy” allotment.

These are not directly related to the delivery of treatment from the health system, but they are distractions to the patient decisions.  If the incentives to the prescriber are different than the incentives to the patient, the patient will more often seek the treatment recommended by the doctor, as this is the trusted relationship.  In survey after survey for many years, the clinician advice trumps the insurance benefit advice, yes, but it also relieves the patient of asking price or quality or convenience questions of the physician.  To this point, in my March 15 2013 I sent out the Health Affairs link to the Kaiser study showing that consumers do not want to be responsible for their healthcare costs, and they don’t want their doctors to be responsible, either.  

If we want to close the health valley that we are in, if we want to use the amazing healthcare resources in our country wisely and widely for all of us, then we have to stop this narrow focus of hospital v doctor v benefit plan v pharmaceutical manager v insurance and get back to the basics:  making healthcare understandable, actionable, and most of all, relevant WITH the patient not TO the patient.  Patient engagement IS the holy grail for healthcare and health improvement.  But it can’t be done around the patient, it must be done with the patient fully present and asking questions and envisioning the future of his or her health.  If he or she can’t see it, he or she can’t achieve it.

But Which Half?

By Kim Bellard, January 30, 2013

Advertising lore credits John Wanamaker, the department store magnate and marketing pioneer, with the famous quote: “Half the money I spend on advertising is wasted; the trouble is I don't know which half.”  It turns out he could have been talking about spending on health care.

The British Medical Journal, through their Clinical Evidence initiative, recently reported that they’d analyzed 3,000 medical treatments that had been studied in controlled, randomized studies.  It turns out that for half of those treatments, we have no idea how well they work.  Indeed, only about a third of the treatments were found to actually be beneficial or likely to be beneficial.  The rest are likely to be harmful.

Sadly, this does not come as a surprise.

We know we don’t know enough.  The vast number of medical treatments have never even been studied in a true clinical trial.  Worse yet, sometimes even when there is clear empirical evidence about which treatments are most effective, that information does not always sway physician behavior, or does so only very slowly (for example, see this study on the use of heart stents versus medication therapy).

There is no shortage of reports of unnecessary or even harmful care.  It’s even scarier when that care is associated with high costs.  In no particular order, one could cite recent controversies with spinal fusions, hip replacements, or chemotherapy drugs.   There can be lots of money at stake for manufacturers, drug companies, and health care providers.  That kind of money can distort the question of what is truly in the best interests of the patient.

Many employers, payors, and researchers have been pushing for “evidence-based medicine” for many years now.  EBM focuses on making sure that treatments have appropriate research to support their effectiveness, and in getting the word out about such treatments.  One of the many initiatives from ACA was the Patient-Centered Outcomes Research Institute, which is charged with conducting research to provide such evidence and funded by a $1 head tax on people covered by insurers.  And, of course, AHRQ probably is wondering why we need a new organization to focus on EBM, given their many efforts on effectiveness.

In time, this may all become much easier, as more patient data become electronic and more connected, and we can make more use of computing power to track what truly happens to patients under various courses of treatments.  I mentioned a couple examples of this in my last blog, citing Optum/Mayo’s new initiative and meta-research studies in lieu of clinical trials.  Another example comes from Archimedes Inc., a firm founded by David Eddy, who was one of the early pioneers of evidenced-based medicine.  Archimedes claims to use its advanced mathematics and computing prowess “to run clinically realistic virtual trials on any population and create compelling evidence to make decisions in health and economic outcomes research, policy creation, clinical trial design, and performance improvement.”  Apparently HHS thinks they can, as it hired Archimedes last year.

Most physicians I know are very bright, care very much about their patients, and work hard to stay current on the medical literature.  Unfortunately, the latter is virtually impossible to do, given the sheer volume of that literature.  Even when there are clear results about which treatment is truly the most effective, the research doesn’t usually come with a guide as to how physicians can implement the associated changes to their practice routines.  It’s as much of a question of change management as it is the evidence to make the change.

It would seem that the situation is tailor-made for clinical decision support tools, which seek to provide clinicians with information on treatment options, potential outcomes, and possible contra-indications at point-of-care.  Unfortunately, we may not quite be ready for them.

Last summer The Annals of Internal Medicine published a study on clinical decision support systems by Bright, et. al.  They did a meta-analysis of studies on CDSSs, and found ample evidence of their efficacy in improving process measures, but sparse results on their impact on clinical or economic outcomes.  Whether this is due to the limitations of the underlying studies, the CDSSs themselves, or how they were used by clinicians is unclear. 

Similarly, KLAS Research recently released results of their survey of health care providers on their satisfaction with clinical decision support tools.  The results cited a general level of frustration, especially due to lack of integration with EHRs and “alert fatigue” caused by ineffective targeting of alerts. 

Worst yet, according to new research from the University of Missouri, patients don’t seem to trust treatment recommendations from physicians who use CDSSs, believing them to be less capable than physicians who make decisions unaided.  Patients don’t even like it when physicians consult with other physicians before making a recommendation!  They think their doctor should know everything.  I blame television for this – on medical shows like Grey’s Anatomy or House physicians pull up the most obscure diagnoses and treatments strictly from memory, without ever having to consult any reference materials.  Nobody’s memory is that good. 

Clinical decision support systems aren’t going to replace doctors; they are simply tools to aid health care professionals, much as a stethoscope or a thermometer does.  One can imagine a future where CDSSs -- and EHRs -- fit seamlessly into patient visits, providing real-time, interactive information while with the patient.  The line between evaluation, documentation, and clinical decision support should blur, in order to more accurately diagnosis patients and determine the best course of treatment.  

In the meantime, it’s somewhat of a crapshoot.

A recent study by Deloitte indicates that 62% of Americans believe that, in fact, over 50% of U.S. health spending is wasted, which is up from the already high 51% in 2009.  The message about necessary spending may be getting out, but consumers may be getting the wrong idea – only 18% thought the problem was not using evidence-based treatments, versus 69% who blame fraud and abuse in the payment system.  In other words, the problem can be blamed on greedy crooks, not on well-meaning health care providers.  Defensive medicine and unnecessary paperwork were each also cited by about a third of respondents. 

I agree that fraud, defensive medicine, and inefficient administration contribute cause us to spend money we shouldn’t, and each should be addressed, but I suspect more of unnecessary spending comes from well-intentioned treatments that aren’t really best for the patients.  As professionals, health care providers should be more stringent about basing their treatment recommendations on evidence that truly supports them.  More importantly, as the people whose health is going to be impacted by those treatments, it’s incumbent on us to demand that evidence.

Maybe one day we’ll have Star Trek’s tricorder to non-invasively diagnosis or even Star Trek Voyager’s holographic doctor to treat.  Maybe someday nanobots will fix all our ills without our even being aware of their work.  All that is in the future.  For right now I’d settle for simply being able to know the odds that a recommended treatment will actually benefit me.

Accenture on Independent MDs in the near future: Fewer of Them; With More Performing Subscription Based Services

By Clive Riddle, November 2, 2012

Accenture has just released a new report: Clinical Transformation: New Business Models for a New Era in Healthcare. They found that  “over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57 percent in 2000 to 39 percent in 2012. By the end of 2013, Accenture predicts this number will likely drop further, to 36 percent.” More interesting, it that “by the end of 2013, Accenture also estimates that one-in-three doctors remaining independent will offer patients with subscription-based services, such as telemedicine or online consultations, for sustaining profit – a trend that is expected to increase three-fold over the next three years.”

Accenture’s Kaveh Safavi, M.D., J.D., tells us “More independent physicians are offering subscription-based services as a way for patients to customize their care experience. Meanwhile, patients appreciate the opportunity to supplement their existing coverage with premium, subscription-based services, such as same-day appointments and online prescription refills.”

While this blends with concierge medicine concepts, but the possibilities for what physicians potentially could develop as supplemental premium services could be quite interesting. Of course, for those doctors under health plan managed care contracts preventing balance billing, chartering into premium service waters might require considerable navigation.

Here are some other findings from the Accenture physician survey:

• 87 percent of physicians surveyed cited the cost and expense of running a business as a chief concern.
• 65 percent joining health systems said they expect to make the same or less compensation than in private practice.
• 61 percent cited business operations as a main reason for seeking hospital employment rather than remaining independent.
• 53 percent cited electronic medical record requirements as a main reason for leaving private practice.

Remember Who the Customer Is

By Kim Bellard, October 17, 2012

An organization called OpenNotes – primarily funded by the Robert Wood Johnson Foundation – recently released a very interesting study that supports the concept that patients do want to participate in their care with their physicians.  This probably doesn’t surprise patients, but may surprise many physicians. 

In brief, the study allowed patients of three geographically disparate primary care practices to access their doctor’s notes (electronically).  The study included over 13,000 patients from 105 physicians.  The vast majority of patients did view at least one note, and survey results indicate that such viewing notes made them feel more in control of their health and improved their medication adherence.  Contrary to physicians’ concerns, such viewing did not lead to longer visits or to more questions outside of visits.  About 60% of patients wanted the ability to add their own comments to the notes, while one-third wanted to approve the notes’ content (something adamantly opposed by the physicians).

It goes back to one of what I think is one of the central problems in health care: those in the business of health care are doing things about patients, but not necessarily for patients.   

Health records are the case in point.  They are maintained about patients, but are written in a jargon that is virtually unintelligible to lay consumers (and, in the case of paper records – often illegible as well!).  The concept that they belong to the patient in any real sense would come as a surprise to the health care professionals who keep them.  Meaningful use requirements are going to quickly force providers towards more patient access to information, such as clinical summaries of visits and summary of health information.  The easiest solution to this is likely to be a patient portal with a view into an EMR, but that in itself doesn’t mean the view is useful.  Please correct me if I’m wrong, but I don’t believe any of the “meaningful use” requirements relate to how meaningful the information is to consumers.  It is telling that the requirements for how many patients actually view or download the information is very weak – only 5%.

Those in the health care business talk in a language of ICD, CPT, HCPCS, DRG, NDC, DSM, to name a few; throw in insurance terminology to complete the task of confusing consumers.  Each of those grows ever-more complex and insular, driven by needs for more detailed analysis, billing, legal protection, and other purposes.  Now we’re increasingly moving towards widespread use of various quality indicators, which are similarly very well-intentioned but may not quite be answering the questions consumers have, or should have. 

As best I can tell, no one in the health business – physicians, hospitals, payors, labs, IT vendors, etc. – really like the complicated languages that have evolved around them, and all would argue that the complexity greatly adds to the expense of running their business, but I don’t see any groundswell to simplify the situation. 

One might have thought that the movement towards consumer transparency might ignite such pressure, but that hasn’t seemed to have happened.  Transparency is one of those things that everyone is in favor of conceptually, but the details of how to do it and whether consumers will use it remain open.  UnitedHealthcare recently found that only 14% of survey respondents use the Internet to comparison shop for health care treatments and services, compared to 75% who use it to comparison shop for other goods and services, a statistic United hopes to improve through its enhanced myHealthcare Cost Estimator.  Aetna, Cigna, Wellpoint and other Blue plans have their own online cost estimator tools.  

In addition to efforts from payors to help consumers with health cost transparency, there are a number of other efforts.  I had been aware of Castlight Health and The Healthcare Blue Book, but was a little surprised to uncover a plethora of other firms, including ClearCost Health, NewChoice Health, and Change Healthcare.  Some of these are aimed at employees of certain self-insured employers, or members of specific health plans, while a few focus on the general public.  It is admittedly an uphill battle to get consumers engaged in thinking about price and quality, and these various organizations all should be lauded for their efforts to give consumers more and better options for doing so.  That being said, it’s somewhat like the talking dog: it is not that it does it well, it’s just that it does so at all.

All the efforts to make costs more transparent have to wrestle with two key problems: what is the “service” being bought, and how can that service be explained in consumer-friendly terms?  E.g., an “office visit” has numerous CPT codes that could apply, each with its own price, and many visits and procedures are accompanied with other services that have their own costs, which the consumer might rightly view as being part of the original service.  How many of us have had, say, a lab test or an X-ray and then been surprised at how many bills we end up receiving for them?  

At the risk of repeating an overused analogy, compare “buying” health care with buying a computer /tablet from the Apple Store or Amazon.  Computers have their own technical language that can be every bit as arcane as health care, but consumers are not forced to use it or fully understand it to complete their shopping experience quite satisfactorily.  When they are shopping, they get lots of options on price and features, with plenty of reviews, customer feedback, and shopping “wizards” to assist them. 

Buying health care, on the other hand, is more akin to getting your own PC back in the 1970s, which required buying a kit and/or components and then trying to assemble the whole thing yourself.  Health care transparency as we know it begins to look more like giving consumers the prices of each component in your PC and quality indicators from the chip manufacturing process.  Those do mean something, but are not really what consumers want.  The problem is that health care professionals are speaking in Greek (or perhaps Latin!) while we want to hear about our health in our own language.

People talk about “disruptive innovation” in health care, by which they often mean use of various forms of technology.  Technology is going to certainly play an even more significant role, but I have to wonder if the disruption will come instead from organizations which can make the health care experience for consumers simpler –much simpler.  I.e., radically rethink what the “products” are, what the processes should be, and how these are communicated to patients. 

Our health care system has many historical practices and preferences that muddle the roles of the various parties involved in it, but it’s helpful to remember that it all boils down to the patient as customer.  It’s their health, after all.