22 September 2017
Dear Interested Readers,
What’s Inside This Letter and Continuing Worries As the Clock Ticks
This week I enjoyed attending the fourth Annual Thought Leadership on Access Symposium (ATLAS) which was held in Boston and sponsored by Kyruus. I have had the pleasure of serving on the clinical advisory board of Kyruus since 2014 and have attended all of the ATLAS conferences. Kyruus is a Boston based company that was founded with the idea that the referral process in large systems could be improved if there was a tool that matched patients to the right provider. One of the co-founders and its CEO, Graham Gardner is a Harvard Medical School/ Harvard Business School graduate who is a former Beth Israel Deaconess Chief Medical Resident and BIDMC trained cardiologist. The current CMO, Erin Jospe, MD, is a former PCP in IM at the BIDMC and Atrius Health, and first met Graham when he was an intern and she was his resident in the ICU. Both of them are committed to the idea of putting the patient first in the pursuit of the Triple Aim.
Last week’s main topic was patient engagement. The core ideas have been
posted on the Strategy Healthcare website since Tuesday. The discussion in the centerpiece of this letter will attempt to enlarge on the concept of patient engagement as well as connect with other recent posts on innovation, competition, and systems integration. Kyruus is evolving a body of knowledge and a collection of products that support all of these potentially positive mechanisms for moving us closer to:
...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 was amazed by the progress that has been demonstrated over the last four ATLAS conferences. The participation has grown from a few dozen administrators and the rare physician from handful of academic medical centers in 2014 to more than 140 participants from over fifty systems from across the country for this fourth conference. The most remarkable change that I have observed as I have followed Kyruus, and gotten to better know some of the systems that are using its products, is how a straightforward idea about how to improve a single issue to the benefit of patients can have such a large impact on an organization.
The original product was designed to help improve the referral processes for the largest health systems in the country. Those systems typically have a “hub and spoke” architecture where affiliated hospitals are spread over a large geographic region with each hospital in the system surrounded by primary care practices and specialists with offices either in the community or in the outlying regional hospitals. The
Houston Methodist system, where I have visited in the past to see Kyruus in action, is a good example of a system that the “provider match” product of Kyruus was developed to support. Houston Methodist Hospital, famous as the hospital of
Dr. Michael DeBakey, is now affiliated with seven other hospitals that form a network across Houston and its connected suburbs. In such a far flung system timely referrals from primary care to the most appropriate specialist can be difficult.
Imagine the waste, both from the position of the patient and the physician, when a patient travels 25 miles in heavy traffic on the freeways of Houston to see a doctor who is a specialist but does not have expertise in the particular subspecialty procedure that matches their concern. I have had it happen. I have had patients with a recurrent atrial arrhythmia who have failed conservative management and are a candidate for a pathway ablation referred to me when ablation is a procedure that I never performed! The referral was a no value added activity. Likewise, if a system has a physician who is fluent in Russian and the patient is a Russian immigrant who is struggling with English, it would be nice to connect them. The problem sounds easy to solve but there are “many devils in the details.” The solutions, the learning, the insights and the possibilities that have evolved in less than four years are amazing and are the background for the major section of this letter.
I do not know where to insert my concern in this letter, but I must share with you the deep sadness that I feel as I read about the damage in Puerto Rico and Mexico City this week. Puerto Rico has been struggling with enormous debt and many of its people were carrying third world burdens despite being the dependent of the world’s richest nation. I can not imagine the sense of loss that must confront the survivors as they survey the destruction and loss around them and realize that it may be months and possibly a year before many of them have electricity again.
Comparing whose disaster is worse is a useless and silly exercise. I stared at a long collection of pictures in the
New York Times yesterday that tried to transmit both the horror of collapsing buildings and the heroism of thousands of people who were desperately trying to remove the rubble that might expose a survivor. As individuals we can’t turn on the lights in Puerto Rico and we can’t easily get in a line to help move rubble in Mexico City, but we can send money. My wife and I have sent money to Texas and Florida. Now it is time to write checks for Puerto Rico and Mexico. Later after the lights are on and the rubble has been cleared it will be time for all of us to ask what part of the problem we might have been, or what we might do to mitigate future disasters.
Finally, I am really disgusted with the last ditch attempts to repeal and replace Obamacare. I have read dozens of articles and so have you. I have listened to the accusations of a righteously angry Jimmy Kimmel, and the lame responses of the target of his ire, Senator Dr. Cassidy who talks more like a slippery politician than a doctor who understands the challenges that will eventually face the patients and families of Medicaid recipients if his snake oil bill passes. If you have 46 minutes to spare, the best discussion, from both sides of the issues, that I have heard was broadcast on
Wednesday on “On Point” from NPR. Click on the link, then click on “Unpacking Graham-Cassidy: The Latest GOP Health Care Bill.”
I hear that Senator Alexander has declared the era of bipartisanship to be over in the Senate HELP committee. I thought that
Senator Murray’s response reiterating that she will continue to work with Senator Alexander if he will return to the process was a “high road” statement. It is hard to know what will happen next either way. If we have the good fortune to see Graham-Cassidy defeated, will Alexander reengage? No one thought that this would be easy. The only positive in the whole long mess is that more people now understand some of the issues. I fear none of us can imagine the sense of loss that would be accompanied with the total abandonment of the core principles of the ACA. I do not trust the protection of the underserved to many of our great states that have already abused public education and proven that they will continue to foster discrimination in housing, voters rights, or any other concern of a minority who is a challenge to the majority world view.
In
Dante’s Inferno he reports that there is a sign in Latin over the gate to hell that can be roughly translated as “Ye who enter here abandon hope.” Last November, late on election night, that phrase popped into my head. I knew that for me the next four years were likely to be as disturbing as the tour of Hades was for Dante. To quote the description in Wikipedia, which is convenient since I have not read any of the three parts of the
Divine Comedy:
In the poem, Hell is depicted as nine concentric circles of torment located within the Earth; it is the "realm ... of those who have rejected spiritual values by yielding to bestial appetites or violence, or by perverting their human intellect to fraud or malice against their fellowmen"That description seems consistent with the emotional journey that I have shared with many friends and neighbors over these past ten months, although it seems that we and not those who have perverted
their human intellect to fraud or malice against their fellowmen are the ones in the nine concentric circles of torment. I have not abandoned hope, and I know that in the end our society will learn and move forward toward a better place, but on some days it is just really hard to read the newspaper. I have a friend who can tell you the number of days until the next presidential election in 2020, and the next inauguration in January 2021. I’ll be closing in on my 76th birthday when that occurs.
I have the desire not to die before we elect a president capable of embracing diversity and equal opportunity for all humans inside and outside of our borders. I want to live long enough to once again see a leader who is essentially honest and embraces facts as a starting point for policy development. I want once again to have a president who can express enlightened national self interest as empathy and respect for those who are different. I want a government that tries to repair economic inequality and believes that every person who lives in America no matter how they got here is a potential contributor. I want a leader who recognizes that the rest of the world needs us to be a source of continuing hope that their lives might also improve through our wisdom and humanity. I long for a president who believes that we should seek to build trust as neighbors on a small planet rather than focus on our fears and national self interest. What I feared before the election, and have experienced as a harsh reality since the election, is how much ground toward my dreams was lost last November.
Some weeks have been worse than others. This week was pretty bad in a muted way. I feel that we have become numb to outrageous behavior and just shrug our shoulders now when before we would have an expression of outrage or honest disbelief. The president’s belligerent speech at the UN concerned me. His false tweet that the bill presented by Senators Cassidy and Graham would not deny care to people with preexisting conditions was either a blatant falsehood or an expression of his own ignorance and lack of insight. The possibility that he might negate the treaty with Iran was beyond my comprehension. His threat that we might invade Venezuela seemed irrational to me, although other smarter people may see some form of brinksmanship or bold strategy where I see a lack of poise and prudence that are reasonable expectations of our president. I will not be surprised when he eventually reveals that he was just kidding when he expressed concern for the 800,000 dreamers. He consistently exceeds my negative expectations. There seems to be no limit to the degree to which he is willing to depart from decorum and precedent as a response to his base.
I am not sure that the awful piece of legislation that Cassidy and Graham have offered will be rejected. Extending the reprieve of the ACA that we had when John McCain, Lisa Murkowski, and Susan Collins voted no to the “skinny repeal” seems to be coming to an end. Since Lamar Alexander has announced that the brief moment of “bipartisan” hope of beginning to fix the ACA is over, do we just roll over and accept the dilemma of passing the disgraceful bill of Cassidy or pray and work for its rejection? Do we see as a victory the opportunity to help the ACA survive despite the best efforts of Tom Price and the president to continue their systematic destruction of the ACA by administrative abuse? The best hope seems to be that the divisiveness in the House and Senate among Republicans will sustain a wounded ACA and that despite the administration's best efforts to kill the ACA, it will survive because a more enlightened public will not let it die. I fear that we may be in for much pain and continuing loss before we can end the nightmare with the election of 2020.
When the Subject is Patient Engagement ATLAS Doesn’t ShrugI hope that after September 30 if someone were to ask the question what are the biggest problems in healthcare the answer will not begin with living with and implementing the Graham-Cassidy bill. However, no matter what does or does not happen in the Senate before October, I am sure that we will all be dealing with complex and volatile issues. Patients will still be worried about access as well the cost and quality of their care. Hospital and health system administrators will still be facing concerns about the decline in revenue relative to their costs. Physicians will still be worried about their clinical autonomy and financial security. Nurses and advanced practice clinicians will be concerned about all of these things and how to be more effectively integrated into a system that takes them for granted and gives them less professional respect than they deserve.
The fourth Annual Thought Leadership on Access Symposium held this week in Boston was a remarkable experience. For years the GPIN conference held twice a year has been a favorite source of professional challenge and opportunity for growth for me. I liked it because the group was small, the speakers were excellent and available for interaction, the opportunity to exchange ideas and network with people who were struggling with the same issues and concerns I had was optimized, and the focus of the event closely mirrored the challenges of the moment while not losing site of the long term vision of the Triple Aim. Now having experienced my fourth ATLAS conference I can say that it matches many of these concerns while having an interesting similarity to the famous Epic user’s events that Judy Faulkner presents each year. I never attended an Epic event prior to 2009, although our organization began using Epic in 1995. If I had been to one of those early Epic events, I imagine that it might have felt similar to the ATLAS conference.
The balance between enthusiasm for a new and potentially innovative technology and trying to understand and improve the environment into which it will be introduced is a challenge. When I discussed the challenges facing anyone attempting to introduce an innovation a few weeks back, I focused on the disruption to the status quo that innovation created and the resistance that it engendered. I failed to point out that one strategy to overcome that resistance is a process of co creation between the innovator and the potential user of the innovation.
By co creation I mean an intense development process that is a “catch ball phenomena.” The idea and the solutions are tossed back and forth between the creators and the potential users. I have passed along Atul Gawande’s concept that healthcare does not suffer from ignorance, but rather incompetence. We have fabulous technologies that were largely developed through skillful application of the scientific method. We have well trained physicians and other participating clinicians who are eager to apply their knowledge and those technologies to improve the health of individuals and the whole population, but we fail in the distribution and access of those technologies and the willingness to provide compassionate care.
We have not been effective at applying the principles of the scientific method to the implementation and creation of access to our technologies and the knowledge of our clinicians. We are not so good and frequently totally fail at getting the knowledge to the patient or the patient to the knowledge in a timely way that is as efficient as possible for both the patient and the clinician who might help.
Accepting or admitting our ineptitude is a first step toward solving a problem. Studying the problem is the next step. We must observe how the current system fails both patient and clinician. Imagining a solution based on knowledge of what is not working, technologies that might be applied or developed based on what customers and providers say would be better is a third step. Having the courage to test the solution in the right environment with a willing partner, customer, or patient is a fourth step and will more often than not, about 75% of the time, lead to both enlightenment and disappointment. Hitting a homerun on the first pitch is pretty rare. Most of the time the solution was either wrong or only directionally correct and numerous unanticipated issues are encountered. Analyzing failures and partial successes are a fifth step that reveals additional opportunities. These less than perfect first, second, third and more attempts that create a better understanding of what might work lead to answers that are closer to a real solution. I have watched this process evolve like a series of episodes on a Netflix thriller over the series of ATLAS conferences.
Success in healthcare comes slowly. We have learned from Malcolm Gladwell that competence in many things takes 10,000 hours of practice. A review of history suggests new effective therapies require an average of seventeen years from discovery to acceptance. I can tell you that I first started to try to use email as a substitute for an office visit in 1995. That was 22 years ago and patient portals are present now in a minority of practices across the country and none of us yet have effective workflows that give patients the enhanced access that could be possible with the digital technology that exists today.
When I first started listening to the conversation between Kyruus, its users, and the sources of expert knowledge and advice it was bringing to the ATLAS symposiums, the conversation was rudimentary. It was about creating data bases that described the preferences and skills of physicians and making sure that the patient got to the right provider for an office visit. Now the conversation has exploded into discussions of increasing patient engagement, change management within systems, and effective utilization of e-health. During one presentation entitled “Change Management in Regards to Engaging Patient Groups,” which was essentially a discussion of leading change with physicians, I wanted to go up and hug the panel composed of Dr Chi-Cheng Huang of Lahey, Dr. Marjorie Bessel of Banner Health in Arizona, and Dr. M. Alex Schiffiano of Summa Health in Ohio, as the discussion of managing change with physicians became an in depth discussion of the burnout of physicians and all other healthcare professionals. Dr. Erin Jospe effectively drew out all the issues from this knowledgeable and committed trio of physician leaders. I knew I was listening to people who cared when Dr. Huang described his experiences in practice and surmised that the number coming from studies that 50% of doctors had experienced burnout was low. Dr. Bessel thrilled me when she referenced the Quadruple Aim. Dr. Schiffiano was able to compare the realities of practicing at Kaiser, an organization with nearly a nearly seventy five year history of leading change, and at Summa, an organization where physicians are on a new journey from practicing independently to practicing collaboratively. The “I to We” journey is preparatory to improving a system to effectively engaging patients. A system must have the diversity of professionals organized in effective teams to create a supportive environment if clinicians are to be successful in engaging paints in the co management of their concerns. All this from the idea of making more effective referrals.
I would be remiss not to underline the fact that better understanding and managing the “bench strength” and performance of a large medical system can be beneficial in ways far beyond patient convenience and engagement. We live in an age of increasing transparency and many of our clinicians are learning for the first time that data that reflects a view of them that they may not like is accumulating rapidly. Systems managers are quickly understanding that the future will continue to produce relatively lower reimbursements and that to remain competitive cost and service issues can not be ignored.
For years since reading the book,
Moneyball:
The Art of Winning an Unfair Game (2003) by Michael Lewis, I have said that it was the best business book I have ever read. Sadly, over the last twenty years I have read more “business books” and related self help books than novels and biographies. Perhaps you saw the movie starring the ever magnificent Brad Pitt as Billy Beane, the general manager of the Oakland Athletics. The A's were struggling with inadequate resources in a small market. Baseball was dominated by teams with the money to pay players much more than a “small market” team could afford. The co star of the movie was the more endomorphic Jonah Hill who played the “nerdy” data guy from Harvard, Paul DePodesta who could turn data into insight and then insight into the appreciation of value.
One concept they used was that they could win without superstars who had many talents if they could build a team of people who were good at one thing. That matches with “team based care.” Another concept I liked was the realization that in a nine inning game each team had only 27 outs. Okay, so what? The insight leads to the realization that wasting outs was bad. The correlation to ambulatory practice is that the average doc struggles to deliver 27 appointments in a day. Wasting appointments because of a poor match between the doctor and patient is bad. Wasting anything is bad. Finally, getting on base many many times with a walk or a single or any way you could gave a greater yield for the team in wins than hitting a lot of homeruns since even the best home run hitters usually also make a lot of outs. Connecting that one to healthcare is a little harder, but I think that it correlates with doing the little things well.
So what is this all about? DePodesta, who is now working for the Cleveland Browns as their Chief Strategy Officer was the last speaker before Graham Gardner, the CEO of Kyruus, gave the closing remarks that summed up the experience. DePodesta is not an endomorph. He is a healthy appearing guy in midlife with a BMI under 25 who looks like he would be either a good wide receiver or short stop. He was an excellent speaker who touched on the philosophy of Thomas Paine and reviewed the biases of analysis as described by
Kahneman and Tversky. (It’s interesting that Michael Lewis’ latest book is about their incredible partnership that launched Behavioral Economics.) DePodesta informed us at the end of his talk that he was moving his interest in data analysis into healthcare. After reading Eric Topol’s book,
The Patient Will See You Now, he called up Topol and is now working with him at the Scripps Institute.
It is amazing to see where a little idea can take you. In these difficult and frustrating days looking above the weeds and finding the strength to improve will be a necessary competency. The other inspirational speaker at ATLAS was a former Navy SEAL, Brent Gleeson, who used his personal experiences as a SEAL and the motto of the SEALS, “
The only easy day was yesterday” to inspire those listening to remember that the work we do draws its meaning from the patients we serve. There should be satisfaction and personal reward despite the difficulties and the challenges of meaningful work that needs to be done. Our goal is a better system of care that understands that patients deserve and need access to care in a system where clinicians are supported to engage them in a journey toward better sustained health, or as I love to say:
...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…Early Color and The Joys of Fall
Last week my wife and I enjoyed a visit from friends who live in Indiana. They do not come East very often and still have not gotten to Boston, but they now have seen New Hampshire, Vermont and Maine. Its interesting to me that you can easily take for granted the beauty that surrounds you everyday until you see it through the eyes of someone who has never seen it before. The header today reveals the early fall beauty of the Ottauquechee River as it meanders between Woodstock and Quechee before roaring through the Quechee Gorge on its way to the Connecticut River a few miles south of Hanover, New Hampshire and White River Junction, Vermont.
The day was beautiful and the colors seemed to emerge even as we enjoyed our drive. The next day we explored the Franconia Notch and braved the auto road to the summit of Mount Washington. We had done the cog railroad to the top but had never done the road. I not sure if we will ever do it again. Once may be enough for one lifetime, although I must say that a great activity for your last day on earth would be a ride up to the clouds on a clear day at the peak of the fall color on the way to the top of the highest mountain in the Presidential Range and the Northeast. Mount Washington on a glorious day in the fall at the peak of color could be a very picturesque launching pad into eternity.
I am really getting into fall and we are still officially in the first week. Even if the pitching doesn’t hold up for the Sox there may be a lot of fall fun ahead. The weather prediction for me for the weekend is superb. Perfect for stacking wood and other fall rituals. I hope that you will take advantage of checking out nature with some friend or family member this weekend.
