Maybe healthcare IT leaders spend a lot of time reading Socrates or Marx or Locke on the philosophy of human nature and whether we are doomed to repeat mistakes made throughout history, or whether we are free-willed creatures capable of charting our own course through existence.
Maybe these leaders are too busy putting a crank to recalcitrant vendors to pay much attention to the ethereal questions of change and inevitability. But it seems some healthcare information technology leaders are doomed by Sisyphean forces to make the same mistakes over and over again.
In more than a decade of covering this industry, HealthLeaders Media has talked to or surveyed hundreds of healthcare CIOs, CMIOs, physician leaders, nurse leaders and executives of all stripes on what makes HIT projects work and what makes them fail.
Some trends emerged to the point of boredom. In fact, I got so tired of reading case studies that praised the virtues of "getting physician buy-in" that I banned one earnest tech editor from using the term.
Years later, I'm amazed to hear that despite our constant work to bring common mistakes to light, the same gremlins are still with us. This is not to say all or even most healthcare HIT leaders make them, but too many are still…
1. Thinking they own the stuff
It's human nature to make a soulful attachment to our work, especially on a project of as grand a scale and effort as your typical electronic medical records system implementation. An EMR implementation project is often described as a "journey" and can take a decade or more.
The mistake is that IT leaders may forget they are creating a tool to be used by clinicians, not a piece of software design to be admired for its technical beauty. Compromises must be made. Avoiding the dangers of "not getting physician buy-in" is one thing, but truly turning over ownership of the technology to those who use it is a leap of trust that some in healthcare IT are still wrestling with.
2. Putting HIT first
In an industry so woefully behind on automation and information technology, it's a forgivable mistake perhaps that HIT leaders are content at this point to "wire" hospitals and physicians offices for the first-generation benefits of such.
One of the inevitable byproducts of the rush to automate under HITECH meaningful use provisions is that some providers will simply look to "wire up" without taking the time to re-engineer the underlying clinical processes.
The very real fear is that the result will be "really bad healthcare done really fast." The solution is thankfully within reach for hospitals that begin with carefully mapping care processes that need to take place. That process itself has benefits of finding waste and areas for clinical improvement.
3. Not thinking like an executive
At a user's conference where I spoke last spring, one of the speakers before me was Sheila Currans, CEO of the 61-bed Harrison Memorial Hospital in East Cynthiana, KY. Her topic was on how CIOs can become part of the leadership team, including such simple advice as keeping the tech jargon to a minimum when working with executive and clinical leaders on a key project or decision.
In larger health systems, the CIO has moved into a strategic role of running the clinical data enterprise and is looking for ways to grow the business using technology.
4. Always thinking like a customer
True, only a miniscule number of hospitals have the resources, expertise, or mission to develop their own technology solutions and must go to the market to purchase tools. The mistake is in accepting that in every case.
Are there opportunities to work with vendors on site testing or other pilots in exchange for price concessions? Are there applications or workarounds developed by your team that have the potential to be "entrepreneurialized"?
Denver Health, a public, safety-net health system, might not seem an obvious choice for HIT development, but its team discusses ways it has saved money and tailored tools by taking a more active approach to HIT development.
Serial offenders guilty of these four mistakes would not be running a technology program anyway. But every time I think these blunders are ghosts of a bygone era, some leader shares a story of a project gone wrong because one or more has been committed.
Healthcare IT leaders are smart people. I have faith that smart people can change. Or at least avoid a wreck when it's a mile down the road.
First let's dispel one thing about revolutions: no one reading this column who works in healthcare is going to start one, except maybe in your respective capacities as consumers of healthcare. Revolutions come when a critical mass of people—18th-century French serfs or overtaxed colonists—decide there is a better way.
So if anything, the work being done by hospitals, health systems, physicians, and IT companies in creating electronic health records and smart devices is mere road-paving for a new way of practicing medicine that is hopefully not too far off—just in time to save healthcare from collapsing in its own inefficiency.
Eric Topol, MD, cardiologist and chief academic officer at Scripps Health, hopes that his new book, The Creative Destruction of Medicine, will help nudge consumers and a few other constituencies into seeing the true potential of digital health to flip the paradigm, as suggested by the book's subtitle, "How the Digital Revolution Will Create Better Health Care."
"Probably the better term is digital medicine or digitizing human beings," Topol told HealthLeaders in an interview. "We are in a Stone Age of medicine still. In the book I paraphrase a quote from Voltaire that 250 years ago we did not know what we were doing in medicine, and 250 years later we have not made a lot of progress. This is a chance to take medicine to a whole new, precise, participatory era."
There is a misconception, perhaps, that digital healthcare is the realm of "cool gadgets." Topol says the digital shift in healthcare started a few years back with health and fitness wireless devices and apps such as the heart rate monitors in Nike shoes. But cool gadgets are just the start of gathering much more precise data about people and their health. That technology has now moved to devices such as blood pressure monitors that can be worn continuously, or blood glucose monitors.
Imagine the precision if a cardiologist could see a patient's blood pressure tracked over an extended period of time, including during sleep or even at times of stress. "Who stops in the middle of an argument to check their blood pressure?" Topol says.
"I'm not suggesting we are all going to walk around with biosensors continuously," Topol says. "For example, there are more than 1 billion pre-diabetics on the planet, and we have warned them not to become diabetic. We have 400 million of those already. What if they could get their glucose every five minutes just for a week, and learn what are the foods and the lifestyle choices that are putting their pancreas into a high-gear mode we want to avoid? Wouldn't that be a great education for that individual, because each one has his own environment, own nutrition?"
The baseline of innovation in healthcare also has to change, Topol says. Much—if not most—healthcare technology innovation adds to the overall cost. What is needed is "frugal innovation" that bends the cost curve, he says. One promising application is an inexpensive wireless sleep monitor which can provide data on sleep patterns, at a cost of under $100 against a $3,000 overnight stay in a hospital sleep center.
"Now we are talking about the big challenge. Here you have all these great technologies but they are not going to sit well if they have any, any increase in cost," Topol says.
The challenges are immense, especially on the data side. "Each genome you sequence has six billion letters and you have to sequence it 40 times and then you have to interpret it properly," he says. But the day is not far off when you can carry your genomic data on a smart phone, which will have transformative implications for everything from checking drug interactions to predicting disease patterns, he says.
If enough people push for it, and the industry responds, this digital revolution has the capacity to "open windows we have never been able to see through before," Topol says.
"It's getting all this panoramic view of the patient: their biology, their physiology, their anatomy, this high-definition person, which really is transformative." Even revolutionary.
People who make and sell "stuff" love living in a disposable economy. The idea that you can sell a product or manufactured item in such a way that it will need to be replaced by its next version in a year or two or three makes for a nice, repeatable bottom line.
I'm sure many of you can relate to how I spent the holidays, which are the disposable economy at its worst. Like any parent, for me the day after Christmas was for exchanging the karaoke CD player that flat didn't work, and throwing away the radio-controlled helicopter that lasted all of two bumpy flights.
You almost expect anything that has on on/off switch made for kids to break before the box is thrown away these days. Add to that the two-year-old leaf blower that started to smoke and the still shiny kitchen faucet that turned into a garden hose. Even if you did have the time to research and order replacement parts, the market tilts to make it cheaper, quicker, and much easier to buy a new one.
Is it the same with electronic medical record systems? In an industry still as woefully unwired as healthcare, it makes sense to focus for now on spreading access and utilization. CMS' "meaningful use" objectives are meant to do just that and not much more. The core components of meaningful use are all performance objectives that must be met incrementally between this year and 2015.
What is less clear is whether meaningful use will form the foundation of a sustainable, "useful" investment in a baseline IT foundation that can pay dividends much past the 2015 end of the program.
Sasha Kramer, MD, a dermatologist and sole practitioner from Olympia, WA, testified last summer before the House Health and Technology Subcommitteethat she spent $41,349 on an EHR system in 2009, including a one-time grant of $19,964 from the Washington Health Information Collaborative for Health Information Technology. The cash investment was on top of the estimated 160 hours she says she spent on selection and implementation, and a month where her patient volume dipped as she went through integration. Less than two years later she got a call from the vendor.
"I was notified by my software vendor that it had been acquired by another company and that the new vendor's products would not support my current network platform," she testified. "The new vendor offered a different product, but because of the significant cost and concerns about the company's stability, I am looking at alternative vendors. Currently, I am looking at a new system that will cost in excess of $27,000 with $6,000 in annual charges; all of which must come out of my business cash reserves. It's not just the financial investment; I will again have to take time away from my patients to implement and train my entire practice on this new system."
Dr. Kramer describes one of the most wasteful reasons why EHRs and EMRs have such a limited life cycle. Other explanations include compatibility changes from mergers and acquisition, regulatory and data burdens which make systems obsolete, and, of course, performance issues when current systems don't perform or are not accepted as had been hoped.
One reason I never hear for replacing electronic health record systems, though, is from Moore's Law, the axiom named for Intel founder Gordon Moore which posits that computer speed and memory double every 18 months to make the former iterations of everything from core processors to digital cameras obsolete.
IT is and always will be a fluid and ongoing investment. Using a reliable system of interoperable electronic medical records is the single make-or-break operational evolution that has to happen in this decade for healthcare to have even the chance to reduce costs and improve care. There is a difference, however, between a sustained investment in a long-term "utility" and throwing capital at vaporous, "disposable" systems.
The idea behind accountable care is that a diverse team of physicians of different disciplines would combine with other top clinicians including care navigators, social workers and nurses to provide the patient with the best evidence-based care, ready access to information and a team working together.
If ever there were a discipline where the accountable care structure was already being tested, it would be in cancer care, says Ian Buchanan, MD, MPH, Associate Vice President, Oncology and Urology UNC Health Care System in Chapel Hill, N.C., and one of the featured speakers at HealthLeaders Media Rounds "A Programmatic Approach to Cancer Care" simulcast from noon-3 p.m. Eastern time on Friday, Dec. 16, live from Banner MD Anderson Cancer Center in Phoenix, AZ.
Host speakers from Banner MD Anderson Cancer Center include Edgardo Rivera, MD, Medical Director, Vicki Koceja, RN, PhD, clinical administrative director and Michael Bianchi, associate administrator.
Cancer care can seem fractured, often with multiple providers in different specialists and working for different groups trying to coordinate care. And the nature of the disease itself plays a role, he says.
"The nature of care is different. You have a lot of acuity and a lot of need for a protracted period of time," Buchanan says. "There are few other diseases that require so many professionals to be engaged," he says, with the closest comparison being solid organ transplant.
At the same time, "that level of coordination runs afoul of some of the traditional models of medical care." Many hospitals, he says, still may not operate as true service lines and have department or other structures that may not optimize team-based healthcare. Those divisions are complicated by a reimbursement system—including Stark guidelines—that make it difficult to reward independent physicians to participate in coordinated care activities.
Still, patients are increasingly expecting that their cancer care will be coordinated by a unified entity, and public and private payers expect that same coordination to reap benefits in reduced waste and more value.
"More so in cancer than in most other services, there is an overlap between what patients expect and payers want," Buchanan says. "In that sense, cancer care can be the prototype for an accountable care organization."
UNC has deployed nurse navigators who guide patients through their care options and help them navigate care episodes that can last several months or longer, he says. The UNC system also works closely with cancer specialists throughout the state with an inexpensive network of telemedicine tools that keep community physicians engaged in care of patients.
More patients are recognizing the need to go to a major cancer center for their care, though "not necessarily an academic one," Buchanan says, to get the higher level of coordination they need.
In its most simplified form, the idea behind accountable care organizations was to get the healthcare providers and payers in a community to work together to improve care while also reducing its cost. Much of that purity has been lost in the noise of the ACO movement, but in Louisville, KY, Norton Healthcare and Humana are continuing the journey.
Norton, with five hospitals and more than 2,000 physicians, and health plan Humana, headquartered in Louisville but with 10 million members nationwide, began discussions of forming an ACO in 2009, “when we had no idea what an ACO really was,” says Steven Hester, MD, Norton’s chief medical officer.
Norton and Humana have formed the area’s first commercial ACO and together form one of five sites nationwide participating in the Brookings-Dartmouth ACO pilot study. But what started their discussions of working together was a shared philosophy, Hester says.
“I don’t see it really as just an ACO structure,” Hester says, “but how do we provide value. How do we change? How do we look around and see who the partners are who can help us move the agenda forward.”
The pilot study focuses primarily on the 10,000 Norton and Humana employees in the market, with other commercial plans to be added. So far the team has worked through the governance issues such as physician participation and financial modeling, as well as the performance reporting and reconciliation of shared savings.
The pilot has begun to track improvement along several initiatives, including a joint replacement accountability study that has seen a 7.3% reduction in direct variable cost, a 6.7% reduction in length of stay, and a 13% reduction in 30-day readmissions.
Norton and Humana have been working on the relationship for years, but both say that hospitals and health systems need not feel like they are years behind the ACO curve and can begin discussions anytime.
“In moving any market, you start working with the early movers and then the others come along,” says Tom James, MD, Humana corporate medical director. Hester adds that the first Norton/Humana ACO discussions and development were longer because “we spent a lot of time creating the ACO model” that others can now replicate. It helps that Norton and Humana had prior experience managing risk in an HMO, but any market with similar risk-sharing experience would have a head start on an ACO, they add.
The next level of communication will be to the consumers, Hester says.
“We have to help people get to a place where they feel they are getting value,” he says. “They don’t understand what these outcomes really mean.”
Hester, James, and Ken Wilson, MD, Norton’s vice president for clinical effectiveness and quality, will share their experience to date and future plans for ACO execution at HealthLeaders Media Rounds “The Real Value of ACOs,” simulcast from noon–3 p.m. ET on Tuesday, Aug. 16. Register today.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Donald Berwick's story.
So much about leadership is timing. Donald Berwick's timing for leading the Centers for Medicare & Medicaid Services may be the perfect man for his times, or just the opposite, depending on who you ask.
Medicare alone now covers 47 million Americans and accounts for 12% of all federal spending. Some 48 million Americans are signed up for Medicaid, a number that will grow by an estimated 15 million under the provisions of the Patient Protection and Affordable Care Act. The CMS that Berwick inherited was already a massive, influential, but largely stagnant bureaucracy. Berwick's goal is to transform CMS from a bureaucracy into something more like a revolutionary force. He intends on using the reach and power of the federal government to herd elements of a fractured industry in hopes of closing gaps in waste that costs taxpayers dollars and threaten patient care, all while overseeing the most massive expansion of government coverage since the Johnson administration.
Berwick's record as a healthcare shepherd is unassailable. Through the Institute for Healthcare Improvement he founded, Berwick and his team cleverly hooked into the healthcare industry's untapped desire to improve with catchy, actionable programs like the 100,000 Lives Campaign. His critics worry that at CMS, what Berwick envisions would be less like feel-good voluntary programs and more toward British-style universal care of which he has spoken fondly. It was that part of his background that conservatives rang loudly as his nomination was announced. His confirmation never came, and Berwick was installed through the political backdoor of a recess appointment that expires next year.
Even in the space of a few months, Berwick has launched the Center for Medicare and Medicaid Innovation, and has pushed the first steps for the creation of accountable care organizations. During that same time Berwick has been largely withdrawn from the public spotlight, declining interview requests and letting speeches at carefully chosen industry events reveal his plans one layer at a time. Still, many in the industry's leadership hold out hope that Berwick can use his strengths to shape CMS in ways that his predecessors have not even attempted.
"Dr. Berwick's biggest strength is that he understands the current delivery system is broken and, therefore, we need to reform the delivery system as well as access to insurance in order to improve the quality, patient safety, and inefficiencies," says Dan Wolterman, CEO of Houston-based Memorial Hermann.
Berwick's background as a family physician and history of pushing patient-centered leadership will serve him well. "He has a history of caring for the well-being of patients, families, and caregivers, coupled with the vision to see a better way of doing things and the courage to make that happen," says Jeff Thompson, MD, CEO of Gundersen Lutheran Health Systems in La Crosse, WI. Chris Van Gorder, CEO of San Diego-based Scripps Health says Berwick is not only familiar with the industry and its key players, but is proven at "healthcare change concepts" that will be necessary at CMS.
But even with his strengths, the political landmines are being set. Unraveling or even repealing the Act was a recurring theme in the midterm elections. "Change is harder in an atmosphere of polarized distrust," Thompson says. "Too many in politics, medicine, and insurance have power and money as the lead priorities, not the well being of the citizens."
And even with the debate over the cost of healthcare being in the national focus for two years, Berwick still may have the convince the public, Wolterman says. "Dr. Berwick's biggest hurdle is to educate the citizens of this country that our current healthcare system is unsustainable and inefficient," Wolterman says. "We all need to be open to a new way of delivering high quality healthcare in value-driven manner that improves the health of the individuals in our community and that the health reform law, as it is currently written, will not get us to this desired outcome." It does not help that Berwick does not have the political mandate behind him. "He lacks experience as a government administrator and he does not have the full support, or for that matter, the approval of Congress for his position," Van Gorder says. "That means he will not have bipartisan support for changes he suggests to Congress."
Hopes are still high that with his background and unique relationships with the industry that Berwick will, as Thompson hopes, "change CMS from a payer of bills to an organization that helps guide us to better value in healthcare."
Berwick's to-do list is daunting. Says Wolterman: "I hope Dr. Berwick pushes CMS to write clear implementing regulations in a timely fashion that take into account the provider perspectives. I hope he promptly removes regulatory barriers that currently exist which prevent hospitals, physicians, and other providers from coming together to be an ACO. And I hope he convinces congress and the administration to pass a new bill that includes specific healthcare delivery system reforms and individual accountability for health which are missing in the newly passed health reform bill."
In patient safety, much is made of the "rights" in care: the right drug given to the right patient at the right time. In the case of Berwick's tenure at CMS, he may have the right training, background, and industry respect to drive CMS to something new. The key questions remain whether his particular fix is the right dose, and whether the politics, the industry, and the economy are converging at the right time for him.