| 10 June 2016
Dear Interested Reader,
What’s Inside This Letter
This week’s letter continues my effort to systematically attempt to imagine the future of healthcare. The focus this week is on the experience of practice. To be most precise I should deal with each healthcare profession individually. There are certainly different challenges in the future for “interventional” medical specialties and surgeons than for physicians in the “cognitive” specialties, including primary care. No one would expect things to be exactly the same for NPs, PA or RNs. Other independently practicing clinicians: psychologists, optometrist, physical therapist and others will have uniquely different experiences from any physician, RN, NP or PA. I propose to focus in this piece on what will likely be common experiences of practice. As a starting point, I hope that what all practitioners will share in common in the future will be of interest to you.
I would like to draw your attention to a posting from last Friday on strategyhealthcare.com from Melissa Cronin, RN. Melissa writes about the emotional and financial challenges of long term care for her elderly family members and gives good advice for us to consider based on those experiences. An abridged version of my letter from last week about likely experiences of patients has been up for your examination since Tuesday. I hope that you visit the site regularly and if you have something that you would like to post please be like Melissa and send it to me. I hope that you will hear from Melissa again soon.
The Future of Practice
I recently attended a performance of Cirque Du Soleil. It was not my first time to attend one of these very remarkable presentations. I know a woman who has been to see them perform over the years in numerous locations around the country. She is almost a Cirque Du Soleil “groupie”. I understand why. The costuming and the themes change frequently. Every show is a different display of acrobatic skills, amazing costumes, dazzling sets, precision choreography, live music and thematic fantasy.
Since 1980 there have been about thirty uniquely different presentations. Cirque Du Soleil has more than 9000 performers working around the world and about a billion dollars in revenue, most of which is consumed by their elaborate offerings to amazed customers. Some of the shows are presented in state of the art tents, as was the show I saw at Suffolk Downs, and those shows move from time to time. Some are presented in arenas, as will be true in Manchester, New Hampshire in late August and move every few days. Some performances are “resident” in one location like Orlando, Mexico City, New York and Tokyo. There are five active and different shows currently playing at various venues in Las Vegas.
In last week’s letter I passed on thoughts from David Brooks about beauty and breathtaking awe. I was surprised to realize as I watched the show that although there was much beauty to appreciate in the performance, I was most moved and was awed by the ingenuity that brought it all together. Every performer was talented and taken individually they were entertaining, but it was their coordinated performance that was awe inspiring.
It may be a stretch, but the evolution of the “circus” from a collection of remarkable independent acts and performances into one seamlessly coordinated physical, musical and visual experience seems to me to be a lot like the evolution of healthcare. In both, there have been real changes in presentation and possibility. In both, what you see is an outcome that is dependent on a tremendous amount of behind the scenes coordination. Workflows are executed with precision that always presents the action at the appropriate moment in the live music. There is the coordination of mechanized scenery and other equipment. It was not until I did a little research on Cirque Du Soleil’s evolution that I discovered yet another similarity to healthcare--finance. The greatest threat to their continuing performance has never been the challenge of artistic or engineering creativity; it has been the complexity of financing such a huge operations where there was never a secure return on investment.
The experience is dependent upon the actions of individual performers, and there are stars, but the awe and the impact comes not from the efforts of one but from the efforts of many who may be onstage, behind stage, or in some distant office. Does that sound like healthcare to you? It has not always been that way in medicine and it has not always been that way at the circus.
I have two stories from my childhood that fit with the idea of how the circus has always been exciting for me but has now evolved to something even better. Just as the complexity of performance in healthcare is similar to the modern circus production so too was the circus of the fifties similar to an earlier era of medical practice. Between ages five and eight I lived in Shawnee, Oklahoma. We were in a cultural backwater and those were primitive times. We could barely pick up the signal coming from WKY-TV in Oklahoma City some 40 miles (there was no Interstate, so it felt further) to the West. I think that I was primed to be excited about circuses by what I saw on our flickering black and white TV which we were so happy to get in 1951.
My friend and next door neighbor and I were typically active and imaginative kids. We were “primed” to play “circus” one day in lieu of our usual cowboy reenactments. In our one ring circus he was a “lion tamer” and I was the lion. This event occurred shortly before I started first grade. As the lion, I was perched on all fours on the top of a stool lifted from my mother’s kitchen and placed in the middle of a large sand box in my backyard. His lion tamer’s whip was a piece of rope, and when he cracked the whip to make the “lion” roar, I fell off the stool and broke my arm against the wooden wall of the sandbox. My picture was in the local newspaper as the boy starting first grade with a broken arm.
The other story has even more poignancy for me. I saw the movie “The Greatest Show on Earth (1952)” not long after I broke my arm and was very excited by the circus once again. It was a terrific movie with an all star cast that made it an early “ensemble” film and included Betty Hutton, Cornel Wilde, Charlton Heston, James Stewart, Dorothy Lamour, Gloria Grahame, and Lyle Bettger. Then to my surprise and delight we learned that the real “Greatest Show on Earth” was coming to Shawnee! Their train would bring the circus to us. There would be a big parade with all of the animals going from the railroad station right through the middle of town and out to open land on the edge of town where their tent would have been erected for the big show. It would happen and be over in a day or so and then the circus would move on. Oklahoma is known for its sudden violent weather. The rains that came created such a wash out that the tent could not be raised. I have never experienced such disappointment as I did when I heard that the circus would pass by us and go on to its next stop. Years later I caught up to the show and enjoyed it with my children at the Boston Garden.
Back in the fifties the circus was a collection of individual acts. In fact, a three ring circus frequently had three acts going at the same without much connection other than that they were under the same “big top”. The evolution of the delivery of healthcare may be behind the change process in the circus over the last forty years. In many places and in many organizations medical practice remains a collection of independent processes with each provider exercising “clinical autonomy” that was not much different than the independence of a circus star of the fifties and sixties before the model offered by the touring circus began to fail as documented in the history of “The Greatest Show on Earth”.
Today’s circus succeeds by breaking more than the formula for the old show. Today’s circus has radically changed how the show is developed and delivered. Now the performers blend their skills into something that has many levels of artistic coordination and presents its audience with an even more interesting experience. The challenge to all medical providers now is whether or not they can blend their offerings into a new effective systems of care with innovation providing creative new tools and workflows. Can we follow Cirque Du Soleil’s example and produce a more awe inspiring production for the benefit of our patients as we improve experience of practice for our providers? I think so.
In Lean we talk about “a reason for action” and then progress through an analysis of the current state to a description of what something more efficient and effective would look like, an improved or ideal state. Formulating a concept of what would be better allows an analysis of the gaps or barriers between what is and what might be. After the problems and the possibilities are thoroughly vetted, by those people who live and work in the system, then a solution or process is proposed and tested. As more is learned from both positive and negative outcomes to the experiments, tests, and pilots, we are able to evolve and confirm solutions that were triggered by the reason for action and envisioned in the ideal or improved state. The cycle begins again after reflecting on what has been learned and can be applied to the next cycle of improvement. As the songs says, “It’s often easier said than done!”. But the more you do it, the more you learn. I would be surprised if some sort of process of continuous improvement and learning is not a part of the success of Cirque Du Soleil.
What you may not have noticed is that for the last quarter century in healthcare we have been involved in one huge slowly moving improvement process. In the nineties we articulated the problem, our reason for action, as care characterized by error, poor safety, high costs, and limited access. Most importantly we began to recognize that our delivery of care was designed more around the convenience and financial needs and interests of individuals and institutions that provide professional services than around the needs and concerns of the patient. We diagnosed ourselves as being inadequately “patient centered” with our self interests more of a daily driver than the safety, equity, timeliness, efficiency, or effectiveness of the care we were creating. That was harsh and has been hard for many to accept and even fewer have found the will to change. Nevertheless things are changing.
“Crossing the Quality Chasm” is about the progression from “current state” to ideal state. It began with a gap analysis and the description of the barriers to better care. It only vaguely suggests the competencies required to achieve the ideal state but is a great descriptor of the components that will be present when we have better care. I see Primary Care Medical Homes, “meaningful use” of EMRs, ACOs, bundled payments, the focus on population health and many innovations exploring new delivery tool like group visits, patient portals, smartphones and telehealth as examples of the “experiments” to test partial solutions to our collective reason for action which is now articulated by many as the Triple Aim plus One. We have learned the importance of measurement, but we are still learning how to manage the intrusiveness of measurement to the flow of care delivery. We are struggling to better integrate our need to measure with the practicalities of delivering care.
The fact that we are in the midst of a huge change process from which no one individual or institution will able be to hide, avoid or long resist is evident every time you talk to anyone who delivers care. We have all been forced to consider changes that we would have never individually chosen or been able to consider, even though our previous and current results have demanded improvement. The personal impact that this has had on providers of care has been hard for everyone and devastating for many. If you really want to ruin the day of a physician, just inform them of the payment changes that are coming their way in the near future with MACRA and the need to pick a path, FFS, MIPS or APM into a future that they do not understand.
Let’s face it. Before we envision the future let’s recognize the obvious and admit the existence of the current anger, fear, frustration and ultimate soul sucking burnout that is felt by so many people who chose a profession because it once offered the attractive dual opportunity of the joys of meaningful service to others and secure personal finances. Now most providers of care want to talk about their frustration and professional disappointment as they daily struggle with the endless tedium of practice laced with increasing regulations and the real risk of increasing financial vulnerability. The “chasm” that is referred to in “Crossing the Quality Chasm” is an abyss into which we have looked and into which many of us have fallen. We are attempting to build bridges but they are inadequate so far.
At this point, in preparation for thinking about the future, I want to reintroduce some of the ideas I discussed after hearing Don Berwick’s talk about Era 3 which he gave at the IHI meeting in Orlando last December. You can listen to the speech online, but IHI also offers a neat seven minute video in which Don cuts the presentation down from fifty five minutes.
Don describes Era 1 as going back to Galen and the Greeks, like Hippocrates, and running up to sometime in the last thirty years. Much like the circus of the ‘50s, the workflows of practice and our clinical values did not change much over this very long period. Don and I entered our practices at Harvard Community Health Plan near the end of Era 1, in the mid late ‘70s. In Era 1 physicians enjoyed the trust of their patients. “Trust me, I am a doctor!” was not a joke. It was an expectation. Physicians had the ability to exercise their prerogative in all issues of patient care without much need for transparency or collaboration. Patients had no choice but to follow. The profession expanded the science of medicine and focused on mentoring successive generations of physicians to perpetuate its values.
The expansion of our healthcare enterprises and the insurance and finance issues in the 70s, 80s and 90s associated with HMOs, Medicare and Medicaid introduced Era 2 and its focus on accountability, “scrutiny”, measurement, incentives and “doubt”. No longer were physicians and caregivers explicitly trusted without documentation. Measurement was introduced with vigor about the same time Ronald Reagan famousy said, “Trust, but verify!” That need to be accountable, measure performance, be scrutinized about potential fraud and abuse and have incentives connected to performance changed the relationship enjoyed in Era 1 between providers and patients. The consequence of the need to verify performance and tying compensation to a fee for service charge master that then is reviewed again and again with doubt that is even hard to verify with questionable though onerous measurements techniques has brought us to the state of practice that is now bemoaned by so many clinicians.
Era 3 is Don’s recommendation for the future of practice and the core of my prediction about what clinicians might look forward to as the foundation of a better practice experience. Don seeks to “harvest” and improve what was good from Eras 1 and 2 while jettisoning what no longer works or is now destructive. Don puts this all into one image that I have lifted as a screenshot from the seven minute presentation that I suggested that you review. |
| | The focus on research, education, and values in Era 1 is foundational but we need to “avoid Professional Prerogative at the expense of the whole”. The issues in Era 2 require backing off from excessive measurement, discontinue complex compensation systems built off monetary incentives and give up the excessive focus on finance. It is my personal belief that the words of wisdom from Sister Irene Kraus, “No margin, no mission!” have been grossly distorted from her meaning and have served to justify some pretty bad practices. Don suggests shifting the focus back toward mission from our obsession with finance.
Don’s ideas may seem naive until you look at the “new” components of Era 3 on his up side of the image. By “committing to improvement science” we are shifting to a strategy of “efficient and effective, quality care” to maintain financial stability by taking less to do more. I am not so Pollyanna as to ever expect healthcare systems to ask for their revenue to be reduced but it would be great if they could equate waste reduction with revenue. “Listen, Really Listen” is an admonition to put patients first. In the midst of a raucous political campaign where political ads range from PG14 to R rated, protecting civility in healthcare has an elevated meaning. It is the equivalent of treating everyone with respect, even as we are trying to make “America great again”. It is the core concept of Lean. Finally, transparency is the antidote for a loss of trust and the need for excessive measurement to verify quality.
I am not taking the easy way out from my self assigned task of envisioning the future of practice, but just as I said in the discussion of the experience of patients in the future when I extolled the advice from “Don’t Stop, Thinking About Tomorrow”, I see movement toward a better future for practice. I talk to entrepreneurs in a variety of start ups and consultancies who are convinced that they can produce tools to support clinical performance and work flows that lessen the burden on clinicians and improve the experience of practice as they improve the experience of receiving care, all while lowering the cost of care and improving its quality. They have done it in other industries and they will do it in ours, if we can give up the mythology that holds us in the status quo.
As much as I enjoy the “art of practice”, when my time comes to need complex care I would prefer algorithms and workflows applied to my care that are driven by big data and the knowledge of the best practices that have worked over the faulty memory and limited data base of the most experienced and renowned practitioners of the art of medicine. We need no longer to base management decisions in clinical practice on the random recent experience of self proclaimed experts and the frailty of unsupported human judgement.
A great doctor with great tools working in an environment that has been engineered for her needs and the needs of her patients is the positive view of the future that both clinicians and patients can share. The “art of medicine” should be employed to better “know” the patient as an individual and manage ambiguity when information is not available. We should embrace and celebrate our ability to articulate and evolve consensus around “best practices”. I am increasingly convinced that although it may not happen tomorrow, within the next decade we will make huge progress in the direction of the “Triple Aim plus One”. It is a reality that without an improvement in the experience of practice we can never expect to have
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
Spring Into Summer
At this time of year the dance between spring and summer is slowing down. As we approach the longest day of the year in less than two weeks, the trees in my neck of the woods have finally gotten close to their full complement of leaves. There are still buds to be seen here and there and the bright green of newly hatched leaves is still observable among the darker green leaves that have been around for a little longer. Spring in all of its beauty is finally giving way to summer.
The loons came back to the lake several weeks ago but the real signal for me that summer is here is that mother Loon has taken to her nest as you can see from the picture in today’s header. It is a great shot taken for me by my wife with her Nikon that can get in close while still giving mother Loon the comfortable distance she needs. Loons are a real example of population medicine in New Hampshire. The state cares deeply about them and monitors the population at least as closely as it follows the care experience of its human citizens.
Counts of the loon population vary from year to year but there are less than 400 hundred breeding pairs that produce less than an average of one click for every two couples per year. Loons are extremely vulnerable to lead poisoning from ingesting lead fishing weights and several die from lead poisoning every year. Laws ban the use of lead tackle but loons still die. On my lake we had a death last year. The autopsy revealed lead poisoning. Our couple has not had a successful pregnancy in three years despite the special “island” that has been provided that you can see in the picture. Over the next few weeks I will be monitoring our couples’ progress as they trade off the work on the nest. Gestation is about 30 days, but last year our loons sat on their nest for a month and a half. The last two weeks were like having a close relative be hopelessly ill in the ICU. The family’s persistence was inspiring.
I hope that you have a chance to “get into nature” or go someplace like a circus this weekend with your friends and family. I believe there are insights to experience and lessons to be learned in the most unlikely places. I am hoping that you will round a corner on some city street, country road, trail in the woods or by the shore and be surprised and awed by the beauty and complexity that awaits your inspection.
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| | Be well, send me your thoughts or a little piece to post, and don’t stop thinking about a better future for us all,
Gene
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