| 26 August 2016
Dear Interested Readers,
An Overview of This Week’s Letter
This week’s letter is the fourth and concluding installment in a series that began following my visit on August 1st to the Iora “nest” (administrative headquarters) located in downtown Boston on Tremont Street in the heart of the Freedom Trail. The letter describes my visit to the Iora practice in Hanover, New Hampshire and introduces you to the terrific people that I met there on August 15. Mixed in with the description of the visit, I offer some observations of Iora’s current challenges. My observations are informed by my own experience at Harvard Community Health Plan during its first twenty years. I try to convince you that innovators must be prepared to face challenges even when their effort is a “greenfield” attempt because their greenfield is in the midst of a very large ‘brownfield” world. John Donne was right when he said:
No man is an island, entire of itself; every man is a piece of the continent, a part of the main...
I think that rationale applies to medical practices as well as individuals. The intent of the effort is to inform you that this theme also applies to you as well as to Iora and to every attempt to improve healthcare through innovation. It connects nicely to the experience I tried to describe in the last two letters when the lovely island of HCHP was forced to build its causeway to the mainland of healthcare.
This weekend will be the last non holiday weekend of the summer. Indeed the traditional summer freedom from school is already over for many families. Across the country many children who attend public schools have shouldered their backpacks this week as they marched off to another year of study and socialization. Of those that remain in the fleeting freedom of summer, many will resume their journey next week toward the accumulation of the information that will be their orientation to the real world of work. Labor Day has lost its status for most students as the gateway to fall and the return to the classroom.
Perhaps our children and grandchildren start the next cycle of education earlier and earlier because there is so much to learn, but something tells me there are other operational concerns. Whatever the explanation they trudge under the weight of more than their backpacks toward a future more uncertain and challenging than they probably realize. They are resupplied for what lies ahead with a fresh collection of sharpened pencils, a rainbow of magic markers, clean notebooks for each subject and perhaps new clothes sized with the hope that they might last until Christmas. Some may even have new iPads or laptops to add to the weight of their new backpacks.
And then there is baseball and politics. I do not know what it means but I find that there are just about as many comments on sports and politics in these letters as there are comments about healthcare strategy. If you want straight healthcare sans Sox or minus my long and winding stories with subtle poltical messages, let me suggest that you notice that strategyhealthcare.com has settled into an every Tuesday routine. For the content of the that Tuesday offering I have adopted Joe Friday’s famous saying on Dragnet, “Just the facts, mam”.
Dartmouth and Iora Health, Partners in Innovation
As I look back over the last six weeks, I am very grateful for the response I received from Dr. Marc-David Munk who is a Senior Medical Director and VP for Accountable Care at Iora Health that followed the July 8 letter. The July 8 letter discussed barriers to innovation in healthcare. If you have read the last three letters or the associated postings on strategyhealthcare.com, you know that Dr. Munk invited me to visit Iora Health, an organization founded about six years ago as an innovation in primary care. You may also remember that the initial visit to the Iora corporate offices included a long conversation with Iora’s cofounder and CEO, Dr. Rushika Fernandopulle. Following that conversation Dr. Fernandopulle invited me to accompany him on one of his regular visits to the Iora practice site in Hanover, New Hampshire which is operated in partnership with Dartmouth College, King Arthur Flour (an employee owned company) , and the New England Carpenters Health Benefits Fund.
Iora now has 29 practice sites in eleven cities with plans to create more and more sites. They are in a period of expansion. All of the sites are partnerships like the one at Dartmouth. Each site has a defined population that is eligible for its services. The focus at the Dartmouth practice is on employed individuals who are not on Medicare and their dependents who are over 18. Some Iora sites, like the partnership with Turntable Health in Las Vegas which serves employees of Zappo’s, do serve families. Some sites developed in partnership with Humana and Tufts, are serving Medicare populations.
The Hanover site is one of Iora’s older sites and was opened in March 2012, a little over a year after the New Yorker article by Atul Gawande that introduced so many of us to Dr. Fernandopulle and the work that he had done in Atlantic City with Atlanticare Medical Center. In Atlantic City the Iora model of care lowered the total cost of care for hotel, casino, and hospital workers while improving the satisfaction, outcomes and measured quality of care. Many of those patients were immigrants who were isolated by culture and language.
After my conversations with Dr. Munk and Dr Fernandopulle I had been impressed with the similarity of Iora’s basic methodology and the ideas that were at the core of Dr. Robert Ebert’s thinking when he established Harvard Community Health Plan in 1969. As I searched the Internet for more information about Iora and Dr. Fernandopulle, I became even more convinced of the similarities. For example I discovered that both Dr. Ebert and Dr. Fernandopulle encountered significant resistance from the status quo. Ironically, for Iora the resisting status quo was Harvard Pilgrim Health Care! There is an article about this resistance from Boston.com writen in 2005 when Dr. Fernandopulle’s forerunner to Iora, Renaissance Health, was fighting to establish itself. In the article Dr. Fernandopulle defended the practice and described his commitment to innovation:
For the past several years, I have worked on a project to create a radically better model of care. A model that would result in both increased healthcare quality and decreased costs. Based on research conducted through the Harvard Interfaculty Program for Health Systems Improvement, we have built an innovative primary care practice called Renaissance Health located on the Arlington/Cambridge border. By leveraging the most advanced information technology, empowering patients to play a much bigger role in their own care, and changing our paradigm of care delivery, we are building a new model to deliver better and more affordable healthcare.
Based on the conjecture that all innovators face barriers that are somewhat similar, I had written two letters describing my experience with HCHP in its early days with the idea of then doing some comparisons after visiting an Iora site. As the visit to Dartmouth Health Connect came closer I was hoping that my experience there would support my hypothesis and whether or not it did, I hoped that the visit would open my eyes to a greater understanding of what Iora was doing and the barriers that stood between its current state and its vision.
The offices of Dartmouth Health Connect are located in the heart of Hanover on Allen Street a few steps off Main street, just before it collides with the Dartmouth campus. I live about thirty miles south in New London. Indeed, our little critical access hospital in New London buys its management from Dartmouth and I frequently see a helicopter fly over as it carries one of my neighbors up to the care that is available at the Dartmouth-Hitchcock Medical Center. Hanover is where my wife and I go to do most of our shopping and to catch a movie like the new Matt Damon flick that we had seen just two evenings before I met Dr. Fernandopulle at 7 AM for coffee and conversation at the only Starbucks between Manchester and Montpelier.
I frequently shop on Allen street. There is a really cool folk art store that is nestled next door to a deli and old time convenience store. The folk store looks transported from the backside of Harvard Square or from eccentric Hawthorne Street in Portland, Oregon. In fact Allen Street is a generally funky street that could be found near many colleges. In the “folk store” you can buy hemp shirts and all sorts of exotic and New Age literature and music served up with aromatic potions. Just across Allen from the folk store is the side door of the Dartmouth Bookstore and behind the bookstore was a favorite sporting goods store of mine, “Omer and Bob’s” where I would occasionally buy shorts, running shoes and other outdoor gear for running and winter sports. I picked up some items for next to nothing at Omer and Bob’s moving sale a few years ago. They did not move far. Their old retail space is the same space where you can now find Dartmouth Health Connect, the Iora practice I was visiting. You can take a tour of the space online.
Over coffee Rushika, everyone calls him by his first name, described his own journey from the idea of being a surgeon when he was a Harvard Medical student to a residency in medicine at the MGH and a Master's Degree in Public Policy at Harvard’s Kennedy School where he was influenced by people like healthcare economist David Cutler. His relationships and early work experience gave him the opportunity to become the Executive Director of the Harvard Interfaculty Program for Health Systems Improvement after he had spent some time at the Advisory Board Company.
It was great to hear him describe what I had already learned from my own reading about him. He related how, from his position at Harvard, he attempted his first effort at innovation by building a new primary care practice called Renaissance Health, located on the Arlington/Cambridge border. It was there that he introduced a new position called “care partners”. The idea was the product of observations that he had made on a mission to the Dominican Republic. At Iora the position was renamed “Health Coach” and is a major component of Iora’s current innovative approach to patient care.
As his story unfolded it was obvious that he had remained true to his intent to “create a radically better model of care”. His intense focus on this vision seemed as genuine as Dr. Ebert’s focus on mission and vision. His story corroborated all that I had been able to read in my online research. Each step in his evolution as an innovator had been a combination of learning from the previous step and an ability to add to the idea through collaborations that were offered because of his extraordinary ability to attract and engage interesting and talented people as he pursued his desire to improve the delivery of care. In that way the Atlantic City project launched Iora, and since moving on from Atlantic City, each step in Iora’s growth and development has created still more and more opportunities.
During our early morning conversation Rushika told me the story about how the Dartmouth practice came to be. What I heard reinforced my impression that his skills include a core competency as a collaborator. Iora’s success has been built on collaboration with business partners that can see that their responsibility to provide medical care for a specific population can benefit from a partnership with Iora’s prepaid, no copay, focus on on effective primary care that reduces total medical expense as an attractive alternative to the status quo.
Dartmouth’s President at the time Dartmouth Health Connect was launched was Dr. Jim Yong Kim who was formerly at Harvard Medical School and wanted to have a practical site to collaborate with the theoretical concepts discussed and developed at the Dartmouth Institute. The conversations about the project included professors and practitioners at medical school and the Dartmouth Hitchcock Medical Center like Dr. John Butterly, Executive Vice President of Medical Affairs, DHMC who was supportive, Dr. Al Mulley at the Dartmouth Institute whose research and development of shared decision making is aligned with the Iora model, and Dr. Joel Lazar, who was the Section Chief of Family Medicine at DHMC. Rashika succeeding in getting Dr. Lazar interested enough in the project to shift his practice to the new model and become its local leader.
While browsing the Internet I discovered that just like the early resistance to Harvard Community Health Plan that I described in my last two letters, not everyone in the community was delighted with the idea of Iora coming to Dartmouth. One blogger bluntly asked whether it would be just a “concierge practice for the healthy” much like some of the detractors of HCHP who described that attempt at innovation as Horrible Care for Healthy People.
It was as Rushika and I moved our cars from Main Street around the corner to Allen Street that I discovered that Dartmouth Health Connect was the new occupant of the Omer and Bob's space! As we enter the backdoor we were met by a very enthusiastic woman wearing a plastic tiara. Robin Rice-Voight, RN is the practice administrator and with Dr. Lazar forms the leadership “dyad” (my term not theirs) for the practice. She has a long history in nursing and is a great source of nursing expertise. Wearing her tiara she was bubbling over with renewed enthusiasm after just returning from a month of hiking and camping out west. We were invited into the conference room where everyone in the practice met at the start of each day for a “huddle”. The first order of business was Robin’s expression of thanks to her colleagues for an experience that could never have occurred without their support.
I felt at home immediately. As an amateur Lean engineer I realized that Iora was utilizing aspects of “Management for Daily Improvement” and ‘Visual Management” as well as demonstrating the philosophy that everyone is a contributor to the care and everyone needs to be informed in the process of collaborative care. In Lean philosophy and practice we are very clear about the primacy of the people who are doing the work.
HIPAA rules were followed and I signed a form acknowledging the necessity for confidentiality regarding individual patients. As I was signing, I learned that each of the Health Coaches took turns in rotation leading the morning meeting. You can see the room on the Internet tour if you clicked on the link above. Two large screens were connected to a program in Google Drive that was the guide for the meeting and where data was entered for later reference by the team.
There was a white board on the side wall where more information about work in progress was observable, along with a reference to the Triple Aim. I snapped a picture with my iPhone and it is the header for this letter. I later learned that the medical record and the various tools for practice have been largely developed by the staff through Google Drive which allows the clinicians to create and modify what works for them before the tools are finalized as part of the IT platform of Iora.
The Health Coach who led the meeting I attended was Gabe Wegner who became a Health Coach at Iora after gaining experience as a sports medicine professional in the Midwest. Later I would observe her in collaboration with Dr. Laura Duncan who is one of the three physicians in the practice. There are five established health coaches and one new one, Ali Price who was just beginning the on boarding process and was present for her first meeting. Ali’s background has included work in nutrition and she had lead classes in cooking in the area. You can view all of the bios of the team and appreciate how the position of Health Coach is open to anyone who is interested in people and service. There is standardized training, but I had the impression that much like the training of physicians in the hospital, the most effective learning occurs as work is being done in collaboration with more experienced professionals.
During the meeting, after I had been introduced to everyone and had heard the pertinent elements of their personal stories, all of the calls, admissions, discharges, transfers, and interactions of the weekend were reviewed. There was consideration of the work ahead for the day. It was clear that everyone worked with everyone. Each of the coaches has a tight relationship with about 350 to 400 individual patients. Patients connect with the practice and their coach in the way most comfortable to them. Later at the front desk I picked up a sheet describing “Chirp”, the collaborative medical record and patient portal. Beyond using the tool to communicate with their coaches and physicians, patients are invited to contribute “data” that is important to them including their weight, blood sugar and blood pressure.
Toward the end of the team meeting the agenda became “The Department of Small (and absolutely awesome) Victories”. Everyone enjoyed offering celebrations about patients who had reached some threshold of engagement or informing their colleagues about some project completed through collaboration. As I witnessed the enthusiastic exchanges among this group of teammates it occurred to me that it was highly unlikely that burnout or a sense of isolation would ever be a threat if this sense of unity of purpose can be maintained. I wondered though, based on my experience with the stress of growth, whether or not there were safeguards in place to protect this fragile ecosystem from the stress associated with the need to grow.
From the meeting the group broke up to go to see their patients, make calls, answer emails, and continue case discussions between physicians and coaches. With the exception of the last item my first reaction was that from this point on “this is just nuts and bolts” primary care. A closer look showed me that I was wrong. Just looking into an exam room revealed an insight. If you look again at the link that is a tour of the site, you will see as I did, that there is a large computer screen on the wall with a semicircular desk with three chairs in front of the screen. The patient, the patient’s coach and the doctor look at the data together. It occurred to me that if your objective was to pump as many patients as possible through your practice every day, then this would look like a barrier or a luxury that you could not afford. If your belief is that engaging patients improves their outcomes,, and that engagement enables people to be healthier, and that healthier people use and need fewer expensive medical resources, then this approach may, on closer scrutiny, be an improvement and the current “least waste way” to provide primary care.
After checking out the exam rooms I began to observe patient flow and schedules. There were no 15 minute appointments. Visits were scheduled for thirty minutes or an hour and the first person to see the patient was the coach. Everyone was attempting to stay “in flow” with the information coming into the collective “in boxes”. Robin and the health coaches seemed to have a way of deciding who was “up” for an urgent call, if the patient’s coach or physician was not available. I was reminded of the choreography that had so impressed me at Cirque du Soleil. I did not understand how they did it, but that was no problem because they did, and everyone always hit their mark.
I spent most of my time hanging out with Dr. Laura Duncan. Gabe and Laura allowed me to sit in on their conversation about shared patients. It occurred to me that I “had gone to the gimba”. I was where things were happening. One big concern that they shared had been discussed at the morning meeting and they continued to wrestle with the problem together: how best to inform one of their patients who had a breast biopsy at a local hospital that the pathology revealed a cancer. The outcome of the discussion was that Laura would first find out whether the physician who had done the biopsy had communicated anything to the patient. After learning as much as possible they would contact the patient and offer an appointment to her and whomever she wished to bring with her that day or whatever day was most convenient for the patient to discuss next steps.
I felt that this was a “causeway” event. As long as care could be provided within the environment that they controlled it was easy to stay in flow and optimize the patient’s experience. Care that needs to be acquired “across the causeway” with specialists, purveyors of technologies, or with hospitals required extra work by the coach and clinician if Iora was to continue to maintain the patient experience that was their goal. If their patient was to experience care that confirmed Iora’s claim that they were “Restoring Humanity to Healthcare”, then Gabe and Laura had a lot of work to do because the rest of the world did not share their goal and was not making it easy for them.
The biopsy had been done the previous week by a “circuit riding specialist” in a community hospital in Lebanon. Locating the doctor was not easy. It took a few calls to learn where the doctor was doing her business on this Monday and then more time to find out what that physician might have done or said about the results. The whole process took up a significant amount of Dr. Duncan’s time as she made multiple calls to find the doctor and learn what had happened.
Gabe and Laura had reasoned that their patient would know immediately that the biopsy had revealed an unfortunate result when they called. The only humane strategy that was available after the fact of the outside biopsy done by a physician that they did not really know was to bring the patient in as soon as possible. This is a problem that many PCPs face and establishing more efficient “causeway connections” must be on the “build list” for Iora. Improvising when the process of care with outside suppliers has not been established is a common source of wasted time in primary care and a contribution to healthcare waste across the country. It will be interesting to see how Iora builds the reliable bridges that its patients need.
At first I was surprised that the pathway was not more efficient, given Iora’s relationship with Dartmouth Hitchcock Medical Center, but then I thought about the often unreliable communications with our suppliers at Atrius and my observation that even within the AMCs and medical systems in Boston there is plenty of opportunity for improvement. I have seen the same issues within most systems where the whole “supply chain” of care is theoretically under the control of one board. Iora has done well to abolish its internal silos and now Laura and Gabe were facing the well defended silos of the outside world.
I have witnessed tens of thousands of clinical interactions. I have not been a fly on the wall in any conversation with a patient that was a better demonstration of empathy and respect than the conversation that transpired over a series of calls that informed the patient and quickly connected the patient back to Iora, Laura and Gabe. I had departed before the visit but can imagine that “humanity was restored” once care was back within the practice.
When I just stood in the middle of the practice and watched what was happening, I was impressed that underlying the continuous collaboration was a palpable respect that you could hear and see in every interaction, whether the transaction was between colleagues or with a patient. I reasoned at first that maybe they were like a family who had a visitor and were just on “good behavior”. As time passed I became convinced that the feel was real and not a put on for me.
I noticed that part of the corporate paraphernalia lying around was a small squeezable rubber cube. On each face of the cube there was corporate lingo that had been imprinted when the cube was created.
- Demonstrate Courage
- Feel Empathy
- Bring Creativity
- Act with Passion
- Serve with Humility
The sixth face had the corporate line “Restoring Humanity to Healthcare” and the other five faces were obviously components of that objective. Then I saw that someone who worked in the practice had inked in “Embody Hospitality” on the face of the cube that said “Restoring Humanity to Healthcare”. It was yet another example of the fact that the people doing the work understand the objectives and can improve the work.
Throughout my stay I focused on conversations with health coaches. They were all remarkable people and you can read most of their stories if you click on the link to the “bios”. One coach whose bio is not available is Dave Peckinpaugh. I learned that Dave had a background in healthcare delivery science and had just come back from an extended stay in England where he had been a part of the Symphony Project, an NHS funded effort to innovate and provide more patient centric care for the population of the South Somerset region. You can rest assured that Dave and I have continued an email connection and some coming Friday you may learn more.
After the use of Health Coaches, a second most obvious part of the Iora methodology is the focus on behavioral health. The PHQ 2, PHQ 9 and the GAD 7 are used almost as often as a stethoscope. Amanda Rice, the embedded social worker, is available for immediate engagement and consultation.
Rushika had come to Hanover in part to have a regularly scheduled meeting with the practice’s partners at Dartmouth. As he and Joel departed for that meeting, Dr. Duncan and I crossed the street to have lunch at a local Thai restaurant. It was a tremendous opportunity for me to discover what her personal feelings and ideas were. I was not surprised to discover that like so many of her colleagues, she had local roots. She was trained at Dartmouth but then had ventured to Utah where she, like Joel, had practiced in the Indian Health Service. I could not help but think that had she been looking for a job at a time before she was born when Dr. Ebert and Joe Dorsey were creating Harvard Community Health Plan, she would have been a perfect fit. She is patient centered, mission driven, committed to the search for better ways to practice and so impatient for the realization of the Triple Aim.
We decided that we must stay in touch. I hope that proximity and shared objectives will allow both of us to continue to grow in our understanding of ways to vault the barriers that face innovators or plot a path around those roadblocks. I am sure that there is much more that I can can see and understand through her eyes on the frontline of care improvement and innovation. Perhaps this will not be my last report on Iora! The road ahead challenges the pioneers at Dartmouth Health Connect, but they press on toward the Triple Aim. Just look at the picture if you do not believe me.
North of The Border
It is a strange thought but we live closer to Montreal than we do to New York City. Quebec is just a little further and that is where I have spent the last several days. In retirement you can go places between Monday and Friday while everyone else is at work. Vermont is so beautiful that it is difficult to stay focused on getting to Quebec, but the anticipation of returning to one of our favorite North American cities kept us moving.
My love of history was fostered in part by my adolescent reading of the historical novels of Kenneth Roberts. In two of his earliest works, Arundel and Rabble in Arms, he focuses on the early Canadian expedition of the Revolutionary War led by the then valiant Benedict Arnold. The expedition was a disaster leading to the unsuccessful attempt of the American forces at the Battle of Quebec in 1775. The most famous battle of Quebec was Wolfe’s victory over Montcalm on the Plains of Abraham in 1759 which made Canada a British territory. It was a battle that neither General survived.
Even if history doesn’t interest you there is plenty of walking to do and beautiful scenery to inhale as you look across and down the St. Lawrence River. 10,000 steps in Quebec is going to include a lot of up and down unless you confine your stroll to the Plains of Abraham. A new fact for me was that the Abraham who owned the plains was one Abraham Martin, a farmer, and not the shared patriarch of the three Abrahamic religions.
I dread the trip back. When we went through customs going into Canada it was not much more difficult than going through the Weston Tolls on the Mass Turnpike. Across the way I could see three or four lanes of cars in lines more than a half a mile long creeping up to border. I guess our agents are doing a good job trying to keep unsavory Canadians out of Vermont and New Hampshire.
I take my Sox with me wherever I go. The return to first place this week was more than I expected or hoped for. I think that my annual wish that they still be in contention for the playoffs come Labor Day will be granted this year. The first time since 2013! We will see. I need the Sox to be playing baseball until late October to protect me from spending too much time thinking about the Presidential election. The questions are whether they have learned from all that has happened and can they avoid the mistakes of late season fatigue. If you missed Andrew Benintendi’s fabulous catch on Monday just click here. I was really upset when on Wednesday when he suffered a knee injury. My fingers are crossed with the hope that some magic will bring him back soon and sustain the Sox in the interim. I fear his injury may have been the beginning of a difficult time. After he was out the Sox lost in eleven innings on a freakish play and yesterday lost again. My only consolation is that baseball is better than listening to the empty rhetoric of politicians.
There were a few chilly nights early in the week. Just enough to confirm that summer is just about gone. The school buses will be back on the road next week so make the most of this next to last summer weekend. You may not have a chance to walk on the Plains of Abraham but I am sure that there is some place near you that is worthy of your attention and a good site for a long contemplative walk. |
| 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
Dr. Gene Lindsey
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