On the Science of Healthcare and Healthcare Delivery

August 11th, 2013

The growth and volume of new scientific discoveries over the last century contributed to  many of the greatest advances in the science of healthcare.  With this massive collection of knowledge comes a challenge to those who practice medicine.  The challenge is, how do  we consistently deliver, in a timely manner, what we know works to the people who need it the most.  It has been suggested that the bench to bedside lag is 17 years. (Balas & Boren)  That is, it takes almost two decades from the time we discover what works to the time it becomes an accepted part of clinical practice.  We’ve become very good at the science of healthcare.  Where we are lagging is the science of healthcare delivery.

There is a famous quote from Cecil B. de Mille’s movie , The Ten Commandments, where Yul Brenner playing the Egyptian Pharaoh Ramses II says, “so let it be written, so let it be done.”  In healthcare, it appears we’ve built this assumption into our system.  Unfortunately, just because we write it (science of healthcare) we cannot assume it will be done (science of healthcare delivery).  While they are deeply related to each other, it cannot be assumed that one will always, consistently and quickly follow from the other.  Just over fifty years ago Everett Rogers published Diffusion of Innovations which describes the theory of how innovation is adopted across a social system.  We are still evolving our understanding of how this applies to healthcare.

While it is important for us to continue to advance the knowledge base of the science of healthcare, the next century will need to focus on the science of healthcare delivery.  If we are to seriously undertake the challenge of population health management, then it will need to be built on the foundation of what we already know works.  One of the greatest challenges for the 21st century will be learning how to “let it be done”.


Robotic Surgery and the Smartphone

July 28th, 2013

Recently I was cleaning out a closet and found a box of old cell phones.  Each one was an upgrade in technology and each one was a reminder of how quickly technology can progress.  The collection of cell phones ranged from the Motorola StarTac to a “vintage”  Razr.  The latest edition to the collection is an iPhone 4 which was replaced with the iPhone 5.  The StarTac was once considered one of the 50 greatest gadgets in the last 50 years.  Compared to the latest generation of smartphones, it pales in functionality.

There were multiple reasons why this happened, but there were three leaps in technological enhancement that help to explain this.  It comes down to markedly improved capabilities in processing, networking and apps.  Data processing on laptops alone has increased 1000 fold in the last 20 years and continues to improve.  By 2020 it is predicted that handheld devices will be capable of several 100 Gigaflops (GFLOP), which can be 100 times faster than current home computers.  In addition, the cost  per GFLOP has plummeted from $640/GFLOP in May 2000 to just 22 cents in June 2013.  So what does this have to do with robotic surgery?

In a June 2013 Medscape interview, Dr. Joseph Colella, the Director of Robotic Surgery at the University of Pittsburgh Medical Center commented that one of the advantages of robotic surgery is, it is a computer technology.  We are placing a computer, in the form of a robot, between a Surgeon’s hands and the patient.  As advanced as that technology seems today, it will pale in comparison to what we will see in the coming years.  Imagine the possibilities when that computer’s capabilities in processing, networking and applications is massively increased.  We witnessed it with cell phones over the last two decades and we will likely see it  in robotic surgery.

In a July 2013 Medscape interview, Dr. J. Kellogg Parsons from the University of California at San Diego pointed out that the benefit is dependent on the procedure and the patient population.  While it still remains to be seen what procedures make the best use of robotics and which population of patients benefit the most from its use, this will become more obvious with time, just as we saw with the evolution of laparoscopic surgery.  Cost will need to decrease and this will likely happen with reduced costs of the technology and competition.  It’s hard to believe but we may one day be comparing current robots used in surgery to the old “brick” cell phone.  BTW, the brick cost $3,995 when it premiered.  With a two year contract the iPhone 5 cost $199.  Yes, it can happen.

Is the MD,MBA Worth It? (Part 3)

July 15th, 2013

Six years have passed since I began the MBA program and 4 four years since I graduated.  So, after all this time, is it worth it?  The one-word executive summary is…yes.  My previous posts (Part 1 and Part 2) reflect my views when I was in the thick of it and working on completing the MBA program.  Now it is time for further reflection.

7) One of the great benefits of adding the additional letters after your name is that it sends a signal to the market.  Whether you are pursuing an MBA degree or completed one, that information tells the market you are ready for a change and are doing so with serious intentions.  There is a marketplace out there that is constantly looking for new talent.  If you have an MD or DO after your name, then you are probably already on a specific clinical career path.  An MBA degree sends new information about you to the market.  The new information is, “I’m interesting in a different path than the usual one”.  It may or may not involve a clinical career, but at the very least, it will be distinguished by an education in business administration.  There is a market for those equipped with an MD and MBA degree, and that market is very interested in finding you.  This is one way you let it know you are interested in finding them.

8) Just as there is a language for those with an MD, there is a language for those with an MBA (or equivalent business experience).  An MBA gets you a seat at the table and helps you learn how to begin to speak the language of business.  As they say in business school, “If your not at the table, then you are on the table”.  If you want to be engaged in the business of medicine, then you need to be at the table and understand what is being said.  Your interests and those of your patients need competent representation at the table.  All too often physicians think their medical degree will be enough to carry them through discussions with hospital administration.  All too often it is not enough.  Typically my biggest contribution in meetings involving physicians and administrators is in translating what each group is really saying to one another.  It is interesting to observe how two groups can speak a common language (English) and not really understand what one group is trying to communicate to the other during a physician-speak vs. admin-speak conversation.  Being bilingual is an asset under these conditions.

9) There is another business school saying which is, “All roads pass through finance”.  If you want to get anything done, that involves capital resources, then you will need to maneuver it through the budget and finance process.  It doesn’t matter if you are working with your own small business or a multi-billion dollar organization.  At the end of the day someone will need to finance your dreams.  Understanding how that is achieved is key to success.  The MBA degree provides the starter toolkit for helping you understanding the “how” of this process.  It was once pointed out to me that cash-flow is like oxygen.  You can wake up in the morning with all kinds of great plans of what you will accomplish that day, but if you can’t breath, there is only one thing on your mind… “I need oxygen”!  In business, cash-flow serves a similar purpose.  To ignore it is to ignore a fundamental principle of organizational survival.  Being a person who has a strong medical background, is versed in the language of business and skilled in the art of traveling the road through finance makes for a powerful combination to help any organization survive and thrive.

10) When you obtained your medical training, you no doubt realized that there are opportunities for leadership development if you are interested.  When you add an MBA degree to your CV/Resume, you tell the world you are very interested.  It distinguishes you and makes you more visible.  A leader, I know, likes to say, “visibility leads to credibility, credibility leads to trust, so if you want to be trusted, you need to be visible.”  Leadership requires trust.  An MBA degree is not only a way to say you are interested in a leadership position but it can also serve as one of many paths on the journey to becoming more visible.  How you build credibility with this new found visibility is up to you.  The MD/MBA path opens the door.  It really is up to you to take advantage of the opportunities it will present once you go through that door.  So is the MD/MBA worth it?  Absolutely!

Miller’s Magical Number Seven and Information Management

May 31st, 2009

There was a recent post on the Medscape discussion forum which referred to an article on the use of mnemonics in psychiatry.  The title of the article is: Mnemonics in a nutshell: 32 aids to psychiatric diagnosis.  Many of these memory aids are simple acronyms such as the CAGE assessment which is used to quickly determine a person’s risk for alcohol abuse.  Of note, among the 32 aids listed is the number of discrete units used for each mnemonic.  CAGE is one of the simplest with 4 discrete units and under delirium diagnosis is “Deliriogenic Medications” which has 15.  For those fans of Miller’s Magical Number Seven this may seem excessive.  In 1956 George Miller, a cognitive psychologist from Princeton, published a paper in which he demonstrated the capacity of our working memory was about seven, plus or minus, two elements (for English speaking people).  It is interesting to note that the number 7 is frequently referenced in our language to describe a list of various elements such as: 7 days in the week, 7 numbers in a phone number7 deadly sins,  7 hills of Rome and , of course the 7 wonders of the world. As it turns out the average number of discrete units for all 32 aids is 7.5 and the most frequently occurring value (mode) is, no surprise, 7.  The range is 4-15 which appears to deviate from Miller’s claim of 7 plus or minus 2.  Since we are referring to a memory aid, the aids with a low number of elements are not critical.  Of the 32 aids only four of them appear to violate the upper part of the range.  Fortunately  a simple mnemonic trick is used to facilitate these memory aids.  Each of these is broken up into smaller discrete units much the way we break up phone numbers.  The 15 element “Deliriogenic Medications” is given the mnemonic “ACUTE-CHANGE-IN-MS”.  Even “WWHHHHIMPS”, which lists the life threatening causes of delirium can be seen as “WW-HHHH-IMPS”. With the massive growth in information in healthcare it seems like we are rapidly approaching the point where mnemonics will no longer be adequate to support human memory.  It has served as a useful bridge but the information age is becoming more and more dependent on information technology as the primary memory aid.  Miller’s Magical Number Seven will not go away though, it will become more important in how information technology presents information to us.  This is the realm of information management.  For healthcare to progress we are going to need to become much better at how we manage information.  It is going to take more than mnemonics to overcome our memory capacity limitations, not to mention the other limiting features of bounded rationality.  The information age will allow us to move beyond satisfactory solutions and endeavor toward optimal solutions.  This assumes, of course, we learn how to manage this vast amount of information in a way that compliments our natural capacity to understand and use it.

The Paradox of Blame

May 30th, 2009

Blame, when appropriately dispensed, assigns responsibility for a past occurrence.  The event that occurred is typically one which resulted in a negative outcome.  As in, “Hey, it’s all your fault.  You screwed up.”  The paradox is, there is an interesting opportunity which becomes available when blame is not appropriately assigned.  As in, “Hey it’s your fault.  You screwed up but… (wink-wink everyone knows you really were not the one who screwed up.)”  The general rule is, none of us wants to accept blame, especially when we were not the responsible party.  There is an exception to this rule and that is when everyone knows you really were not the person responsible for the bad outcome.  This is sometimes referred to as, “taking one for the team.”  By accepting blame, you now become the responsible person (and better team player).  The opportunity granted to you for accepting blame is that you can now fix the problem caused by the person who was previously responsible.  If you fail, then it really is your responsibility.  If you succeed you have now earned the right to the new position of responsibility.  Since you were not responsible in the past, you were not in a position of authority to affect the outcome. By accepting blame, under certain circumstances, you can advance to a new position of responsibility.  This assumes, of course, you learned from your predecessor’s’s mistakes and can affect a good outcome. It’s a risky tactic but one that comes with rewards if performed effectively.  The key is to recognize and guarantee the quid pro quo.  In exchange for accepting blame, you will be given the opportunity to correct the problem.  Therein lies the paradox.  Given the choice between blaming the person truly responsible, who has proven they don’t know how to fix the problem, and “blaming” the person who is not responsible, who can fix the problem, blame sometimes tends to find the problem-solver. This is more common when responsibility is distributed to many individuals, and difficult to assign, or when saving face for the responsible person is warranted, for whatever reason.  It’s an odd thing to say but sometimes “blame” is another way of saying opportunity.

Physicians as Hospital Employees

September 21st, 2008

Hospital administrators view things differently. One of the primary reasons any firm in any industry (health care included) brings an individual who provides a service or produces a product in as an employee is to reduce transaction costsFirms exist because transactions that occur within them are more efficient than if those same transactions occur outside of the firm.  Once the marginal cost of a physician’s services consistently exceeds the marginal benefit the physician provides to a hospital it is in the hospital’s best economic interest to employ the physician in order to control the costs or improve the benefit. For example, as physician reimbursements decrease and their costs increase they must seek alternative revenue streams or practice efficiencies in order to maintain the same income. With the paltry 1.1% raise coming from Medicare and the July 07-08 inflation rate at 5.6% it is not difficult to understand why this is happening. As physicians struggle to keep up it seems it is inevitable they will lean on hospitals to either boost revenue (stipend for call, reimbursement for uninsured patient care) or cut costs (EMR support, medical office space). These are transaction costs administrators are willing to support in order to keep the hospital doors open. When it is less costly to employ a physician than pay these costs hospitals must as a practical matter move toward employing physicians. It’s an expensive choice but when the alternative is more costly it becomes the best alternative to a negotiated agreement (BATNA).  In order for physicians to remain independent they must be able to generate revenue and decrease costs in a manner that does not make them dependent on the hospital. I don’t claim to know where this will lead to in the coming years but I think as long as physicians squeeze more of their revenue stream out of the hospitals they will ultimately increase the probability they will become employees of the hospital.

Transforming Arizona’s Healthcare System

September 20th, 2008

It’s been a busy couple of months between returning to school and starting a new job so I thought I would share a recent assignment I wrote for school.  It’s based on my understanding of a Harvard Business Review article (HBR 9-808-072) titled, Transforming Arizona’s Health Care System: Developing and Implementing the Health-e Connection Roadmap.

In his recent bestseller, The Age of Turbulence, Alan Greenspan recounted an article written by Paul David, a professor of economic history at Stanford, who explained why it took nearly four decades for the electrical motor to displace the steam engine as the primary source of power in America.  When Thomas Edison first demonstrated the superiority of electrical power in 1882 nearly everyone could appreciate its merits.  It was also assumed that it would be just a few years until electrically powered motors would be everywhere and still it would be decades before it happened.  As Professor David explains the reason it took so long is because the process was capital intensive and required a restructuring of the existing cultural, social, architectural and technological infrastructure supporting the status quo, the steam engine.  The same could be said of the use of computers in the evolution of electronic data exchange in our healthcare system. 

            Everyone can see that computers should be able to improve the delivery and efficiency of healthcare.  Just like electrical power it is obvious that computers will displace the status quo, the paper chart, but it has not happened as yet on the grand scale and many are getting restless.  Governor Napolitano’s Executive Order 2005-25 was an attempt to jump-start the process by bringing the state of Arizona’s healthcare stakeholders together to create a roadmap to “achieve statewide electronic health data exchange between various entities in the health care delivery system”.  The driving force behind this is the increasing awareness of the problems that exist in our healthcare system and the recognition of the role information technology can play in the solutions to those problems.

            Since the Institute of Medicine’s 1999 report, To err is human: Building a safer health system, there has been a growing urgency to fix the long standing problems in healthcare.  It is now estimated that there are thousands of injuries and deaths due to avoidable medical errors.  In addition, millions of dollars are wasted every year as a result of redundant tests, missing information and lost productivity.  It has been shown that the use of computers and information technology can not only reduce medical errors but also lead to a significant cost savings over time.  The Governor’s roadmap (Arizona Health-e Connection) was intended to provide a path to improving the delivery of healthcare through the collaborative use of information technology and act to build momentum toward achieving these goals.  So if the merits of this roadmap are so obvious what is holding back the universal acceptance and rapid rollout of this project?

            It may be, as Professor David explained regarding the electrical motor, that we are undertaking a restructuring of the legacy systems that have maintained the status quo and that replacing them involves disrupting the established cultural, social, architectural and technological infrastructure we currently depend on to deliver our healthcare.  It’s not as easy as unplugging the old system and replacing it with a new system.  The new system must be built upon, co-exist, and ultimately replace the old system.  Fortunately the Arizona Health-e Connection Committee anticipated some problems with implementation and attempted to avert them by building a coalition based on broad representation of healthcare stakeholders.  Despite broad representation and the obvious merits of the project roadblocks remain and some may simply take more than a roadmap to overcome.

            Arizona has some unique challenges to overcome.  One issue that must be addressed is that at least a quarter of the state’s population is rural and spread out over a wide geographical area.  At the time of the committee meetings only 13.5% of physician practices used electronic health records (EHR).  With many of these practices classified as small or medium in size and located in areas that exist outside of the main information technology networks it is difficult to bring everyone on board and deliver the same standard of care to all state and Native American populations.  Electronic health record technology also has significant start-up costs which are considered prohibitive in an environment of declining reimbursement and rising costs.  Physicians are skeptical about the immediate return on investment of high cost technology and like everyone else who has seen the price of computers, plasma screen TV’s and cell phones plummet are willing to take a “wait and see” approach.  While waiting may lead to continued errors and cost issues for the system as a whole it may also lead to lower IT costs for an individual practice and the likelihood of a markedly superior EHR when it becomes more affordable.  This is not to say physician practices are the only stumbling block.

            The massive build-up of information technology hardware and software is the result of numerous innovators and firms with a vested interest in the proprietary rights of their intellectual property.  This has resulted in a wide range of vendors, products and services as well as a healthy dose of competition to facilitate the innovative process.  Each hospital and healthcare system has, to varying degrees, invested in these various products and services.  In an effort to seek a competitive advantage for both the vendors and healthcare systems many of these innovations were not necessarily designed to enhance interoperability with one’s competition.  For example, if you are in the business of selling electricity and lamps it makes sense in the early phase of a product or service life cycle to sell only lamps that can plug into your power grid.  As the electrical companies focused on delivering power and got out of the lamp business the new focus became interoperability, which means getting a common standard for electrical outlets so everyone can plug into the power grid.  This may be analogous to what we are experiencing in our healthcare system.  Without standardization within the electronic data exchange networks it will be impossible for everyone to focus on innovating more improved and less costly plug-in products and services. 

            The Arizona Health-e Connection should focus on network standardization and interoperability.  The early days of electrical power dragged on while standards were being established but once they were the realization of the true merits of Edison’s vision materialized.  Once standardization and interoperability are established it will also be critical for stakeholders to agree on what information can be shared and with whom it can be shared.  Any risk of creating a network which provides asymmetric information to privileged entities will sabotage efforts at collaboration.  In addition, once standardization and interoperability are established this will articulate a clear message to the market.  The health information technology industry will be able to focus more capital on innovations that specifically are designed to reduce errors, redundancy, misinformation and costs in healthcare.  Instead of each healthcare system differentiating them-selves by owning a unique EHR that lacks network interoperability they can now focus their attention on systems that utilize network information for improving care.  The real goal after all is to improve patient care and decrease the cost of delivering that care through enhanced integration of the statewide health information system.  Standardization and interoperability eventually worked for delivering electrical power.  Let’s hope it doesn’t take as long to do the same for delivering better healthcare. 

The Patient-Physician Relationship

July 29th, 2008

It was one of the big healthcare stories in today’s New York Times.  It started out by saying:

      “A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.  The relationship is the cornerstone of the medical system — nobody can be helped if doctors and patients aren’t getting along. But increasingly, research and anecdotal reports suggest that many patients don’t trust doctors.”

Right there in the opening sentence, written between the lines, is the crux of the problem.  The author like so many of us put the “doctor” first in the “doctor-patient relationship”.  It’s a subtle but important distinction.  It is essential that the public and those of us in the medical profession learn to appreciate this distinction.  If there were no patients there would be no need for physicians.  Ergo it is the patient that comes first in this relationship.  The patient’s healthcare needs are what created the physician’s healthcare solutions.  Like I said it is a subtle distinction to reverse the order but it says so much about how we view the world of healthcare services.

While I am on this topic you may have noticed a couple of other related observations.  One is that I specifically did not refer to the “patient-doctor relationship”.  In the United States the conventional use of “doctor‘  refers to a medical doctor.  This is not always the case and “physician” or “medical doctor” is the more appropriate term.  Another point is that recently the “patient-physician relationship” is quickly being replaced by the “patient-provider relationship”.  I’ve discussed some of the reasons for this in a previous blog.  Suffice it to say I believe it is because the “cornerstone of the medical system” is changing.  I suspect this is really the reason the trust is breaking down.  The real question is if patients don’t trust doctors who will they come to trust?

The Knowledge Worker & the Cost of Healthcare and Education

July 28th, 2008

The knowledge worker is an expression first described by Peter Drucker in 1959.  Over the last fifty years the knowledge worker has become the most essential and fastest growing member of the workforce.  It can be argued the knowledge worker has always been the most essential member of any workforce but in the information age they have taken on new value due to their vast numbers.  What is interesting is not only the growth in numbers of knowledge workers but also the cost of maintaining this booming generation.

Each age places an extraordinary amount of value on that which most contributes to output.  When we were primarily an agricultural economy value was placed on the land and the means to grow, harvest and bring to market the crops it could produce.  During the industrial age a factory’s plant, property and equipment were the primary assets of value.  In both ages the owners of the land or factory invested a relatively large amount of resources to insure the most efficient use of the assets that were the drivers of production and the creators of wealth.

The times are changing and it is the knowledge worker that has become the primary asset that creates future wealth.  Due to the growth of this member of the workforce is it any wonder that the value we place on health and education has increased?  Education is the way we maintain and upgrade the intellectual capital of the knowledge worker.  Healthcare is not only a way to repair and heal the knowledge worker during the down-time of injury and illness it is a way to maintain the long-term operational effectiveness and efficiency of this valuable workforce.  When we look back on the rapidly rising cost of our healthcare system we may find that one of the primary reasons for doing so was to preserve and protect the knowledge worker and the value they bring to our society and our economy.

Life 101: Elevator Etiquette

June 16th, 2008

With all of the emphasis on reading, writing and arithmetic in our educational system it leaves little time for courses that could also be beneficial to our society.  They would fit under the broad heading of “Life 101”.  These would be a series of courses that teach all that stuff that can make everyday life run much smoother.  For example, how about a short course on “Elevator Etiquette”.  We can start the course by having everyone memorize ten simple rules. 

Rule #1: Pressing the up or down button multiple times does not make the elevator move any faster.  The corollary to this rule is that pressing the button harder (or punching/kicking it) also does not make the elevator move any faster.

Rule #2: While waiting for the elevator do not stand in front of the door.  You can’t get in until the current occupants of the elevator make room for you and they can’t do that unless you get your big butt out of the way and make room for them to exit.

Rule #3: Do not, repeat do not let children under the age of ten press the floor button.  It’s like eating potato chips; they will not be satisfied with just one.  They just can’t resist the urge to press every floor button.

Rule #4: The “close door” button: A) is broken and will never be repaired. B) was never hooked up and was only installed to make you feel like you are doing something by pressing it repeatedly. C) has a delay built into it and the doors will close when the time delay has elapsed. D) once worked but was disconnected because of too many complaints about people closing the doors too quickly. E) All of the above.  (Correct answer “E”)

Rule #5: Under no circumstances is anyone allowed to pass gas.  This is especially true for those who are about to disembark.  That’s just rude.

Rule #6: Unless you have a health problem or are moving things (furniture, packages, baby carriage, etc.) the rule for using the stairs is “one up, two down”.

Rule #7: The elderly, disabled, people carrying stuff (babies, packages, food) and those with nothing better to do move slower and must be allowed adequate time to board the elevator.  (Yea I know it seems to take forever but just remember, some day it may be you who needs that time.)

Rule #8: Regarding speaking on cell phones in public places, don’t say anything you wouldn’t want printed in tomorrow’s paper (or blog).  And BTW, “CAN YOU HEAR ME KNOW!”, speaking louder does not improve your cell phone reception.

Rule #9: As a general rule the personal body space  distance in social situations is about 18 inches (OK, OK it varies by culture but for most people in the US it’s still about 18 inches.).  The personal body space distance in intimate situations is less than 18 inches.  Just because we break from convention to allow more people to fit in the elevator doesn’t mean we’ve become more intimate.

Rule #10: Eighty-five percent of buildings with at least 13 floors do not have a named “13th floor“.  It’s considered unlucky or superstitious to have one.  That’s just the way it is so the next time you are on an elevator and some smart-ass gets on and asks you to press floor thirteen just tell him to press it himself if he is feeling lucky.  (BTW for all of you who live or work on the 14th floor in building that don’t have a “13th floor” it is really the 13th floor.  Sorry to ruin your day.)

Well that is it for today.  If you can think of any more add them to the list.  Who knows, someday we may have an “Elevator Etiquette” course manual.