12 May 2017

Dear Interested Readers,


What’s Inside Plus Good Bye James and Jimmy Speaks Out Again

Silly me. I thought that after the president’s big social event in the Rose Garden to celebrate the House’s passage of one of the worst pieces of legislation ever offered to the Senate for further consideration there would be a pause in the action so we could let our emotions settle back toward a level that required less blood pressure medicine to avoid a stroke. I was wrong.

What was the sudden need to remove the director of the FBI? He still had six years on his term. Was it because the president likes to keep the pot of outrageous political events boiling? Was the action suddenly necessary because Comey was stumbling onto something that was a little too close to home, or rather the White House? My first response was empathetic, although there is no doubt Mr. Comey made some huge mistakes last year, as Hillary Clinton has implied. I do not need to justify my empathy for a guy who finds out that he lost his job from a news flash on CNN while giving a speech in L.A. Hey, we all make mistakes that have consequences, but we are also entitled to a little respect when the boss tells us it’s time to pursue our interests elsewhere. We were told that Jeff Sessions, based on a memo from his deputy Rod Rosenstein, advised the president to finally hold the FBI Director accountable for mistakes made last July and October just the day after Mr. Comey asked for resources to use to investigate how the Russians might have interfered in our election, and almost coincident with the discovery that a Federal Grand Jury is beginning to subpoena witnesses like Mike Flynn.

I am old enough to remember my own shock and outrage on hearing of Nixon’s Saturday Night Massacre forty four years ago on October 19,1973. Historians may not say that was the beginning of the end for the man who swore he was not a crook. But, it was the inept action of a man who was grasping at straws. He resigned and boarded a helicopter to infamy on August 8, 1974 after a very busy ten months losing his argument. [These paragraphs were written Wednesday evening at least two hours before I heard Stephen Colbert say pretty much the same thing. You may enjoy hearing it from a professional.]

At the core of last week’s letter was the very moving plea that Jimmy Kimmel made for making healthcare access that was not limited by preexisting conditions available to everyone. Jimmy’s monologue was consistent with the idea that access to healthcare was an entitlement. We know that in Europe and many other developed societies like Canada, Australia, and New Zealand, plus some places that aren’t so well off like Cuba, this is a truth accepted by over 90% of the population. Not so here, and Jimmy heard from his fellow citizens who consider healthcare to be a commodity that is purchasable by those who are wise enough to figure out how they can afford it, or find an employer who will buy it for them. The big surprise if you listen to the clip on the link is that he interviews Bill Cassidy, the gastroenterologist who is the Republican senator from Louisiana. They model a pretty good example of how future conversations might lead to more productive outcomes. They seem to agree more than they disagree. The conversation was a highpoint in the midst of an otherwise dismal standoff between two different points of view about the future of healthcare.

My biggest discovery of the week was facilitated by an email from Tony Hatoun, a longtime Interested Reader. Tony is not a doctor. He is the co founder and CEO of a very innovative company that produces software for the big players in financial services who structure equities. His son, also an Interested Reader, is a pediatrician and researcher at Children’s Hospital in Boston. Tony is a longtime friend. Our children were classmates and Tony and I were running buddies who completed many marathons together over very many years. On our long runs we often discussed politics, innovative business practices, and healthcare. We kept each other informed about the new ideas that had come our way.

In his email Tony asked if I had read Robert Pearl’s new book Mistreated: Why We Think We're Getting Good Health Care— and Why We're Usually Wrong. He had just heard the author interviewed on NPR. The answer was that I knew who Pearl was. He is the CEO of the Permanente Medical Group who writes frequently in Forbes and other outlets, but I had not heard of his book. Thanks to Tony I can now say that Pearl is the author of a very exciting new look at where we are, why we are there, and how we can move toward the Triple Aim. I am devouring the book. It is a useful complement to the other book that has recently caught my interest, Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.

This week I am quoting just a little bit from Pearl’s book in an exploration of a question about the possible utility of artificial, or rather computer augmented intelligence in healthcare. It is an exciting idea for me and way more interesting than writing about the misadventures of Paul Ryan and cronies, or the eccentricities, excesses and inadequacies of our president.


The Celtics are getting interesting. The Red Sox have not yet become consistent, although they are interesting in a frustrating sort of way. That is enough about both of them. The letter ends with reflections stimulated by Mary Oliver’s recent book of essays.

If I had Three Wishes From the A.I. Genie

As close readers of these notes know, I have long been a big fan of applying Lean process management techniques to healthcare. While I was practicing full time before I became a CEO, I was impressed by the creative application of Lean by Zeev Neuwirth, MD to solve many of the problems that frustrated our staff in Internal Medicine. When I became CEO in early 2008 I pushed our organization to use Lean across the entire enterprise. I knew it would be a huge endeavor, but I also knew that we had to become more efficient and effective because we were triply challenged by the recession of 2008, the expectation of value based reimbursement initiated by the passage of Chapter 58 (Romneycare), and the development of the Alternative Quality Contract of Massachusetts Blue Cross.

At the time we chose Simpler to guide us on our journey. That decision was easy after talking with John Toussaint about the effectiveness of Simpler at ThedaCare. I was also impressed by Simpler’s work with Patty Gabow at Denver Health and by their ability to help the huge system managed by New York Health and Hospitals. Since retiring I have continued to enjoy a relationship with Simpler and have passed on what I have learned in many of these letters.

I was excited a few years ago when Simpler was acquired by Truven. I saw the potential for huge synergies between the data capabilities of Truven and the ability of Simpler to show healthcare organizations how to incorporate the information and insight acquired from the Truven’s data into improved work flows that could reduce waste in healthcare while improving safety and the experience of patients; all done while achieving a lower total cost of care. My excitement was further increased when IBM Watson purchased Truven and Simpler. That move seemed to create the opportunity for practice improvement utilizing the organizing and process management tools and philosophy of Lean with huge amounts of useful data, and the computer augmentation that opened the door to the use of unstructured data. In my dreams I could see how it all would come together. Simpler’s expertise working on the front lines of care with clinicians, and Truven’s huge data resources coupled with Watson’s enormous abilities to analyze and apply information would allow us to solve complex problems.

I do not stake my hopes for the future of healthcare on new legislation or changes in payment methodologies. Those are necessary but insufficient if we are ever going to respond effectively to the challenge to achieve

...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

I believe that the challenge of the Triple Aim requires the re engineering of healthcare and the application of continuous improvement science. Old systems that produce harmful medical errors and consume resources that are disproportionate to the benefit they provide must be replaced by systems that work for the patients and providers, and that are economically sustainable. I am impressed by Atul Gawande’s assertion that we are no longer ignorant. We are inept. We have knowledge and resources that we can not manage effectively to achieve the high aspirations of the Triple Aim. We have not accepted what Robert Ebert told us more than 50 years ago when he said

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

We all experience the resistance of the status quo. In his book Mistreated: Why We Think We're Getting Good Health Care —and Why We're Usually Wrong, Robert Pearl lumps the keepers of the status quo into what he calls the “legacy” systems. The legacy systems in healthcare are happy to accept the continuing profits that our dysfunctional processes produce. Specialty societies, large medical centers, the big five providers of insurance, device manufacturers, and big Pharma constitute Pearl’s “legacy systems”. They like the status quo and the profits that our system of care produces even as all of its customers complain about the price. Paul Batalden taught us that every system perfectly produces the results that it was designed to produce. Systems designed for corporate and provider profits perfectly produce profit.

Writers like Robert Pearl and Elisabeth Rosenthal beautifully describe how these systems work and how they undermine safer, less expensive, and more easily accessed care for everyone. If we are to capitalize on the insights that Ebert and Batalden have given us and move past the ineptitude that Gawande sees, we must learn how to manage complexity, introduce innovations, and learn how to spread what we have learned and developed. Gawande was surely referring to our inability to efficiently spread and implement our newly acquired knowledge when he talked about our ineptitude.

My excitement about the collaboration of Simpler, Truven and IBM Watson has not yet produced the satisfying results that I anticipated. Dreams are easy. Reality requires work. Perhaps others are also a little disappointed in IBM’s ability to translate Watson’s skills at chess and on game shows like “Jeopardy” into healthcare improvements. It would not be the first time that finding the right application for a new and exciting tool proved to be difficult, or that a new and useful tool ran into the resistance of doing things the “old way.”

I was not surprised this week while reading a New York Times report of the annual meeting of Warren Buffett's Berkshire Hathaway to learn that he condemned the Republican attempts to repeal and replace the ACA. Quoting the article:

“Medical costs are the tapeworm of American economic competitiveness,” he said.

What did surprise me was the quote a little later in the article:

Mr. Buffett also argued that executives at Wells Fargo, in turning a blind eye to the creation of fraudulent accounts to meet sales goals, had fostered a toxic culture...Yet Mr. Buffett...stood by Wells Fargo and other Berkshire investments, including United Airlines and Coca-Cola...In contrast, the billionaire offered little defense of one major holding of Berkshire: IBM. Berkshire announced on Friday that it had sold one-third of its stake in the struggling technology company.

Investor’s demand results. On the same day that I read about Buffett’s disappointments and lack of confidence in IBM I read Robert Pearl’ s answer to why Watson was not fulfilling my dreams of its impact on healthcare. Pearl is the CEO of the Permanente Medical Group, the doctors who staff the Kaiser facilities. In the second chapter of Mistreated: Why We Think We're Getting Good Health Care— and Why We're Usually Wrong, he described the issues. I have bolded the big take away at the end of the piece.

At present, there are two schools of thought about how to best use technology in health care. Although both have value, one will have a much more powerful impact on reducing mortality in our nation, and it is not the one most doctors would prefer.

First, meet IBM’s Watson, the supercomputer that took down Ken Jennings on Jeopardy! Using the power of big data, Watson has the ability to quickly find clinical answers buried in millions of pages of medical records. Watson, a machine that’s about the size of a pizza box, is already being used to sift through nearly 1 million new medical studies published in more than 20,000 journals each year.

In the context of how doctors have traditionally seen themselves, Watson isn’t a threat. He’s more like a “Lifeline” from the TV quiz show Who Wants to Be a Millionaire? If you’re stumped, Watson may have a suggestion. If doctors don’t like his answer, they ignore it.

Watson’s capacity and speed are incredible. But he’s not really what doctors need. The problem with Watson isn’t that he can’t do amazing things. His problem is that the amazing things he does rarely add value. Being able to peruse massive amounts of information in relatively short order doesn’t make much of a difference for most medical problems. It is a rare patient for whom a thorough review of every article ever written would be necessary. Besides, Watson can’t discern which papers should or should not be trusted. Achieving the best outcomes is not a matter of discovering the obscure, but rather providing the right care consistently. The biggest opportunity we have as a nation for saving lives is ensuring that every doctor follows the best available approaches every time.

He continues by celebrating Apple’s Siri as the answer that doctors need. Siri fits your pocket and is capable of correcting the problem of forgetting a step in care which he says is the greatest source of physician error. Siri could enforce protocols and decrease harmful variations in routine care. Pearl uses the fact that his father who had a splenectomy for hemolytic anemia and ultimately died as a distant result of sepsis from pneumococcus that could have been avoided if many physicians had not failed to give him the vaccination he needed. He goes on:

Siri can follow doctors from room to room while delivering more than enough memory and computing speed to help physicians diagnose and treat nearly all problems that patients experience...Better still, Siri’s expertise will grow over time. Using information contained in millions of electronic health records, she can be programmed to calculate the probability that a particular patient in the ER is having a stroke or needs a particular cancer treatment.

Not only is she a powerful source of information, but she can also question the doctor’s approaches and make sure the specialist uses the right admission order set every time, even offering up friendly reminders as doctors go step by step through the treatment process.

That sounds great. What Pearl fails to discuss is that both technologies must be incorporated into work flows that are designed to reduce the work clinicians and administrators must do everyday. I do agree with him that Watson as currently used does not benefit the routine care of patients in any way that could make a real difference in the cost of care and little difference in safety or efficiency. Siri is also not being used as he describes. Currently Watson’s utility falls into the “party trick” category. All of this must be considered against the historical reality that the IOM and other authorities teach us that on average it takes seventeen years for any new drug, medical device or change in a practice protocol to be commonly accepted and deployed.

Against the background of reading Buffett’s thoughts about IBM and Pearl’s complaints about Watson, I was asked how I would recommend that Watson be more effectively incorporated into our efforts to continuously improve care. The query was fanciful. If a genie granted me three wishes with Watson, how would I use those wishes? I would answer by thinking about who Watson might help. I believe that Watson has the potential to really help patients, providers, and those responsible for the business of care delivery if its power is effectively deployed at the point of service.

Patients would directly benefit from the systematic application of Watson to the problem of transparency. Patients need comparative data drawn from multiple structured databases about cost. They also need help in choosing which option of care realistically meets their needs. We have never become very good at “shared decision making." They also need outcome data and data about the experience of care of other similar patients. Watson has access to the huge quantities of data necessary to answer these questions, but its capability is not utilized because we do not have the workflows that can bring it into the process of care.

Pearl points out that patients ask friends about who the best doctor is and are impressed by advertising in part because there is no presentation or organization of easily understood information to guide them in their choices. If Watson is capable of assisting an oncologist in finding the best study or the best protocol for a patient, it should also be possible for it to help find the best place and best team to provide care at a price that fits the economic realities and personal preferences that are of concern to the patient. For this to happen we will need more than Watson. The project needs a home and it needs a work flow. The home could be a government agency, a business providing a service, or an insurance company or care delivery system seeking to offer a service that provides it a competitive advantage. Doctors can’t do it alone. Once there is a sponsor, Lean is an excellent way to engineer the reality and move up the continuous improvement ladder from idea to reliably performing asset.

Dr. Paul DeChant has long contended that one of the biggest threats to the Triple Aim is clinician burnout. Paul is correct to note that much of what has become drudgery and the source of frustration and depression for clinicians is created by the combination of poorly functioning systems, increased regulatory demands, the need for detailed documentation for optimal reimbursement, and increasing operational overhead that robs resources for practice support. Many clinicians struggle everyday with computerized “paperwork” and spend much of their time obtaining “prior authorization” and doing other clerical tasks that leave no time for the care of individual patient, much less exercising the use of the tools of population management.

A systematic review of current practice could add to the limited utility that Dr. Pearl sees in Watson. Watson could “augment the intelligence” of every physician across the spectrum from primary care to the most focused and limited specialty practice. Dr. Pearl thinks that Apple’s Siri can monitor adherence to best practices and identify forgotten steps in usual practice like omitted immunization or the failure to provide adequate prophylaxis for infection or manage through ambiguous emergency presentations. Watson should be able to do all of this well, but for it to help us we must learn how to let it make a difference. I believe that Watson’s greatest potential benefit may be its ability to incorporate unstructured data that it has read or “learned” into clinical analysis. Much of the critical thinking and decision making that we do for patients at the point of care involves weaving structured and unstructured data together.

I can remember many times in my office or in urgent care when I would have loved to be able to ask Watson what I had not considered, or based on what I knew, and what was in the literature, whether or not my patient could go home or should go to the hospital. Systems must be developed that integrate human based clinical skills with machine learning. It should be a profitable journey toward an inevitable future not unlike the development of self driving cars. I can not accept the idea that there are not innovative practices that are ready now to start the journey.

My third use of Watson would be as the manager of the mundane. Administrators, clinicians and patients would all benefit by effective incorporation of Watson into processes like filling out forms, requesting prior authorization, complying with audits, assuring quality through reporting to payers and regulators, finding effective and efficient referrals and managing the loop between the request and the return of the answer to the clinician who asked the question. Watson can “learn” these tasks as an assistant that will eventually do more and more of the work.

If I could ask for a fourth wish from Watson, it would be as an application that redefines “top of the license” for every healthcare professional. We all fear the cliff that lies ahead. We are about to fall into an abyss of professional shortages. I could argue that even now we are inadequately staffed to provide care to the 85-90% of Americans who currently have some sort of covered access to care. We must change how care is delivered, and by whom, if we do not want access and service to further decline in the future.

I worked for years in a system that valued nurse practitioners and physician assistants. What I realized was that their efficiency was frequently undermined by the same fears and concerns that made me less efficient. They were often asked to solve or manage problems where uncertainty slowed them down and caused them distress. Would it not be nice to “speak” to Watson or even Siri in the way my son speaks to his Google assistant in any room of his home. He says, “Google what will the weather be this afternoon?” The female voice in the machine then gives him the answer that allows him to leave his raincoat at home. I think that it will not be long until Watson is ready to answer almost any question a clinician might ask. It has long been demonstrated that care plans directed by algorithm get better results than expert clinicians practicing the “art” of medicine.

Maybe you are not ready for a new friend who will augment your intelligence, but I am. I was only given three wishes and asked for four, but I can think of many more. I see Watson as the first of many “new friends” on our healthcare team who are ready to help us move beyond the ineptitude that Gawande complained of toward the dreams of the Triple Aim that persist through our current misery and uncertainty.

Impulsive Purchases and the Relief of A Good Walk

I am an impulsive shopper. My wife jokes that if she takes me to town in tow on a shopping trip, she rarely comes home with something, but I always find something or something finds me. I love browsing bookstores. On a recent trip we passed through Middlebury, Vermont and the Vermont Book Store is a place where I have been making impulsive purchases since 1981. We were traveling with another couple so while my wife and the other woman explored shops, her husband and I set out on our own adventure. I made a beeline to a thrift store where I bought a good jacket because I was not ready for the unexpected dip in temperature and from there we went to the bookstore.

In the bookstore I found Mary Oliver’s new book, Upstream. I hope that you will click on the link because it is to a review by Maureen Corrigan on NPR and it is terrific. It will also show you the cover that enticed me to buy the book full price rather than delaying my gratification long enough to save $10 on Amazon. I do this frequently out of the perverse concept of supporting local retailers. I would hate to see these small bookstores close. The picture on the cover is coupled with the first essay which is only a few pages long and is also entitled “Upstream.” Great writers pack a lot into a very few words. The words that captured my imagination were also echoed on the book jacket.

“In the beginning I was so young and such a stranger to myself I hardly existed. I had to go out into the world and see it and hear it and react to it, before I knew who I was, what I wanted to be.”

Mary Oliver did this as an adolescent in nature. I had to enter the world of the hospital and practice to make the same discovery. Now at the long end of life I find that I use her methodology, going “upstream” into the woods, fishing in streams like the one on the jacket, and walking for miles along country roads to discover who I am and understand what is was that I was pursuing in the professional life that is now over.

You really do not need to be in New Hampshire or Vermont to get to the same place. I did it last weekend a few feet from Flatbush Avenue in Brooklyn, while walking with my family through the “Native Flora Garden” section of the Brooklyn Botanical Gardens. It was just like a walk in the woods. Back home I have been walking under cloudy skies that provide a glorious accent to the reds of old houses, and the greens of the new vegetation on Goose Hole Pond, as you can see in today’s header. More than ever, in times like these, I prescribe for myself and anyone who will listen the healing and reassurance of a good walk as the antidote for almost any concern.

Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene