Money, Medicine and Metrics

A colleague of mine shared and article from the New England Journal of Medicine called "Money and the Changing Culture of Medicine" by Pamela Hartzband, M.D., and Jerome Groopman, M.D. The gist of the article is that the practice of medicine had both communal and market characteristics and that currently the balance is skewed towards the market end of things. For example, physicians are pushed by pay for performance, payors and medicare/medicaid to focus on the cost of care. There is currently no carrot for collaboration with peers or even patients. Additionally the article points out that studies have shown that the introduction of financial rewards into almost any situation tend to reduce willingness to collaborate. Scary!

Perhaps change is in the air though. Word on the street is that the National Quality Forum is considering different kinds of metrics. Metrics that measure things like patient engagement in their own care. Not that traditional quality metrics like the SCIP measures will go away but perhaps pay for performance will start to focus on actually changing the culture of healthcare. This is exciting!

We should be careful though. Just as paying physicians based on efficiency alone doesn't necessarily deliver the right outcomes, encouraging physicians who find the right ways to engage their patients to hold those techniques as strategic advantages may be less likely to share what worked. So I hope NQF successfully finds a way to reward and encourage the sharing of such best practices, among doctors and hospitals alike.

Back in the (Blogging) Saddle

After a week and a half of intensity at work and intensity at home I'm about to get back in the saddle again. If you have for some reason followed my twitter posts recently they are mostly about bread and chicken coops. The work-life balance tipped away from work for a while and it's been nice. I find that once I refuel like this my mind starts looking up and around again vs the heads down daily grind that can come after intense periods of work.

Work has been intense. Strategy development, team building, infrastructure projects and new technology evaluations abound. I like to get deep into a topic, obsess about it and know as much as I can in the time I have. I then come back up for air and a reality check and figuring out how much of each is needed to keep the momentum going requires more art than science right now.

So a colleague of mine gave me a few articles to read recently and I took the opportunity in a longish large meeting to scan them and it spawned a few ideas.

• An article on the effect of compensation on collaboration (negative in most cases) got cross pollinated with what I'm learning about the National Quality Forum's likely future direction on hospital metrics.
• Build vs buy on the Business Intelligence front in payor organizations. What are the lesson's learned for providers and how does that relate to emerging trends on data aggregation vendors as opposed to traditional Business Intelligence vendors.
• The economic recovery legislation and it's impact on adoption of EMRs and even more importantly the execution of those projects.

Today was a good reminder to stop, pay attention to everything going on around me and not just focus on the next steps and the plan. If you don't stop and smell the roses then you might just miss something important...

(Not) Lost in Translation

Today I was given a fine compliment and told that I was a translator. After writing about having to "traverse the stack" and Business Intelligence as a bad word it felt good to hear evidence that bridging the gap between the technical world and the healthcare world is doable by mere humans. Like many things in our culture this talent isn't nurtured early enough and it seems that the school of hard knocks is the primary teacher. For example, how many computer science programs emphasize non-technical writing, non-academic presentation and business skills? It's been a while since I got my Bachelors Degree but I don't see the core of these programs doing a good job in this area.

There are a few ways to try and get there faster. A double major in business management, communications or an MBA. In fact many of the best and most effective translators I know got their MBAs early in their careers and I admire their grace. In a pinch though an organization can help this happen by cultivating these skills internally, not slaying people for making mistakes and committing to the development of their people. These things will evolve into part of a hard-wired culture of learning and culture definitely eats strategy for lunch!

Back to sharpening the saw...

Wordle - Check this out

Wordle automatically draws a picture of all of the words on a site, biggest word being the most common. Here's this blog's wordle for this moment in time.



Apparently I still lean towards being a technology guy. Hmmm...

IT - It's Not About The Bits Anymore

Two things happened recently that made me feel a little closer to the ambulatory care world. First, my sister got a job at a clinic as a business analyst. I'm very proud of her and am excited that she's joining the healthcare IT world! She's going to be great at it.

Second, I was recently at a clinic, wearing my operational excellence hat, doing some value stream mapping. They are going to be implementing an EMR soon and are looking closely at their current state processes to see where they might be able to streamline them. The hope is that doing so will help free up the time and energy that it'll undoubtedly take to get it up and running. I was reminded of a physician's email to a another clinic's project team. The best quote was "if you're not used to working with computers and technology get ready for the pain train!".

The culture and human change represent the real work. The process design and management piece is engaging and challenging. The technology can be equally complex but the truly hard part is helping people unwire the parts of them that rely on the muscle memory of paper, pen and pencil. To rewire those pieces with the habits and skills that make their transition to keyboard, stylus and tablet possible and as painless as possible.

For that and other reasons Gartner and other pundits forsee IT being less about the nuts and bolts. Less about buses, bits, boards and 4th generation languages and more about the relationships, conversations and art of change. I used to long for the good old days when I was a shepherd for a bunch of Digital UNIX, HPUX and Linux boxes. When it was just me, the hardware and a command line. Now that part of my brain has found more joy at home designing chicken coups, garden walls and the occasional bookshelf.

Instead I find myself doing value stream maps, investigating ROIs, understanding changes in CMS core measures and gathering high level requirements. It took me 13 years to get here. My sister was able to step into her first HIT job without ever seeing a UNIX command line or configuring a IP network. She's never hacked a registry or plugged an ethernet cable into a frigid datacenter patch panel. Instead what she has is far more valuable. Ten years of everyday experience working with doctors and nurses while they care for and treat patients. Ten years of immersion in the process of caring for patients. I hope I can keep up!

Richness of Capability - Um, why do I care???

In my post on "Richness of Capability" I realized that I perhaps went a bit out there without explaining why I'm curious about it. Well imagine...

• If we had a way to measure when a foundational technology will deliver way more than it promises?
• If we had a way to communicate and measure when an investment in capability will multiply compound on existing processes?

That's why I'm curious. I also don't think the topic hasn't been looked at, I probably just don't know where the research is or how it's already measured. Topics to consider looking for these answers include innovation, enterprise architecture and information theory. More to come...

The Process and the Technology

Evidence based care (EBC) is coming and I'm pretty darn sure it's a good thing. The thought that my diagnosis and treatment will be based on research that statistically shows the best outcomes gives me some confidence in a world where I get two answers from two doctors on the same question. Last Thanksgiving I was at the table with a friend of my Mom's who is a case manager who focuses on EBC. There are basically three key things you "do" when implementing it.

• Scan the research on a regular basis to find out what it's telling you.
• Assess your processes to find out where you can bake compliance with the correct order sets/protocols into patient care.
• Continuously measure and update based on the results.

Obviously BI tools play a part in the measure piece. Without those you don't have a way to find out if you're getting the results you expected. I'm also very curious about how you turn a culture around to address the process piece. Physicians like to do things the way they like to do them. I suspect that standard order sets aren't terribly popular.

Last but not least how do you efficiently and effectively scan and look up all of that literature and research. What opportunities are there to use technology to search unstructured federated data quickly and effectively. Google of course comes to mind but how do you hone the edge of the search to get exactly what you want.

As a six sigma green belt I look at all of this and think about how beneficial it might be to reduce variability in outcomes and results. As I'm currently learning LEAN concepts I think about how much waste there might be in these systems and how can it be squeezed out, to benefit patients, consumers and the rising cost of healthcare. As an IT professional I can imagine the day when the lines between the process and technology blur....