Embrace Change or be 'Eaten Up'

In the quest for quality care, business as usual won't do. Progress is what change is all about. And there's an upside: When value-based payments really hit, evidence-based medicine may get some traction.

"As we contemplate its contentious present and problematic future, we remain prisoners of its past." —Charles E. Rosenberg.

Change rarely comes easily. Hospitals are currently coping with major shifts in payment models, patient care, technology, and more. These changes are designed to improve the quality of care, but not all them are going well.

Lately, we've see revolts against meaningful use and excessive quality measurement. In addition, data is piling up on the failure of doctors and hospitals to deliver evidence-based care.

So, here's some blunt advice for the hospital industry: Change is constant. Deal with it.
 

Lee Penrose is the CEO of St. Jude Medical Center, a 351-bed Fullerton, California hospital which is part of the St. Joseph Hoag Health system. "In order to embrace a new future, we have to be more comfortable with change," he says.

"We have to be ready to experience our work in a different way. In this consumer-driven industry, were either going to change or we are going to be eaten up."

Still, Penrose, a 20-year industry veteran, says that hospitals are currently dealing with an unprecedented level of change. On his plate: a merger between St. Joseph Hoag Health and Providence Health & Services, a system with 34 hospitals in five states.

Old Days, Old Ways
One way to understand the need for change is to look at what some might call the good old days. In the pre-DRG era, doctors ordered whatever care they saw fit, no one questioned it and insurance covered it.

Patients paid little; they were either too poor or too insured. With no consumer pressure, costs ballooned. Patient experience? Patient stays were longer, the food was horrible, and there was no cable TV. All the doctors were men, all the nurses were women, and all the bosses were white.

Patient safety and infection control measures were not what they should be. And, orders were scrawled on note pads, recorded on paper, and transmitted via courier or fax.  

No one wants to go back there. But, with change, it is good to keep in mind that sometimes things get worse before they get better. Take the implementation of electronic medical records.

Anyone who has ever had to learn a new software program knows it takes time and practice. Until you get that muscle memory, you fumble around with tutorials, lose your work, and make many mistakes before you get it right.

In Epic or Cerner, of course, the stakes are higher than in, say, Photoshop. But you still have to account for the learning curve.

The HITECH Act's Messaging Failure
It usually takes a good decade for any industry to see returns from a large investment in information technology, says Julia Adler-Milstein, assistant professor of information, School of Information and assistant professor of health management and policy at the University of Michigan's School of Public Health. She is studying the implementation of HIT and says there is no reason to think it will happen more quickly in healthcare.

"That was really a failure of the message behind the HITECH (Act)," she told me. "It was sold as, 'You put in these systems and care gets better tomorrow.' There is no reason we should have thought that. This is always going to be a 10-year journey—maybe eight years, more like 12 years. The expectations were never set at that time scale. So, partly, that has led to this great backlash."

Even well-executed changes can be hard to take, but in the case of HIT, users are coping with clunky systems that are not user-friendly, she says. And, it's not always clear to users how all that input is improving care.

And then there is the question of interoperability. All of the players—vendors, policy makers, and providers—share the blame for the inability of many systems to exchange data, Adler-Milstein says. "I think they really underappreciated how hard interoperability would be to begin with, let alone, after you've allowed thousands of different system to be implemented in your country," she said.

Physician Alignment
Another big change for hospitals is the growing ranks of doctors as employees. Healthcare systems are struggling to bring more physicians into their operations in a way that helps improve quality, safety and efficiency, says Peter Angood, MD, the CEO of American Association for Physician Leadership [formerly the American College of Physician Executives.]

Both parties get too focused on the mechanics of the contract, he says.

"Those places that are failing on the engagement of doctors haven't stopped to take that moment and clarify in a transparent way the purpose of the relationship and how to make it work on the short-, intermediate- and long-term," he says.

Beyond financial arrangements, issues that need to be clarified include the scope of responsibility, the amount of clinical work, and administrative work and expectations regarding measurement and outcome results, Angood says.

One way to improve that transitions? Angood recommends that hospitals make sure they have doctors in top jobs. Evidence suggest that "physicians in leadership roles can make the place run better," he said.

In general, good leadership can be key to successfully managing change at hospitals, Penrose says. "As leaders, were called on to help frame the change and put it in proper context and understand and articulate the 'why' behind change," he says.

"If we can't help those around us understand why change is happening, and why perhaps it is good for all of us, all we are going to meet is resistance. It is human nature to resist change and we see it every day."

Finally, it is good to remember that even when a new initiative goes off the rails and creates chaos, it's possible to steer things right. Last week, CMS and the insurance industry agreed to harmonize their quality measures. When value-based payments really hit, evidence-based medicine may get some traction.

HIT? Stop groaning. One thing the HITECH push did do right was drive the adoption of HIT.

"Now we have to figure out how to use these systems well," Adler-Milstein says. That means providers will need a better sense of the day-to-day value of the systems.

She also says there seems to be a consensus that interoperability needs to be fixed: "This high tech investment will be wasted if we don't' get interoperability right. There is a consolidation of focus on that issue that I've never seen before. It means that there is an opportunity to make some progress."

And progress, it could be argued, is what change is all about.