Healthcare Transformation

Improving Quality

I’m reading Stephen Pinney‘s book called How Hockey can Save the Healthcare System and highly recommend it. Why?

The section on Quality addresses one of the most important lessons for Administrators….don’t always trust your reports. Dr. Pinney highlights the problem in his example with the Pre-Operative Surgical Checklist.

According to the Administrator, the checklist was preformed consistently for two years without issue. The problem was that it wasn’t performed correctly. Significant errors resulted and were unreported.

One of the most important lessons that I have learned from working closely with Medical Directors is that they know the business and when they say something is wrong, something is wrong. Administrators need to dig into the details to get to the bottom of the issue rather than dismissing them.

Dr. Pinney and I have uncovered the same issue. Data is often missing and when data is missing – the reports are wrong. For Administrators, they need to understand why the data is missing and take the steps needed to ensure it is consistently captured. It’s a matter of life and limb – literally.

According to Dr. Pinney, these types of quality and process improvements are key to systematizing medicine and achieving the third aim.

Think end-to-end

When you change a process, you have to think about the entire experience of the new process. Why?

In short, you want people to follow the process and have a good experience of your service.

I experienced a very broken process yesterday that saved the owner of it money but put additional burden of both time and money on the user. In my case it was a government process with no way around it but those types of broken processes in the corporate context are ripe for a workaround.

In healthcare there are a ton of workarounds. For example:

– EMR design problematic. Turn off the field requirements.

– Staffing model problematic: Adjust the acuity of the patient population.

– Contracted rates problematic: Drop out of the network.

– Billing and payment problematic: Bill the patient.

Each problem and every workaround has an impact to the patient and their experience of the healthcare system.

The problems with the experience have been compounded by the number of solutions that are not integrated into the system. When everything is piecemeal it makes the system feel more fragmented and difficult to use.

To make the system feel less broken, we need to think about the end-to-end experience of how patients are expected to discover/access, use and share their results with the professional that needs them.

Trust

Transparency is the key to consumer engagement in healthcare. Why? In one word – trust. 

Yesterday I participated in a film being made by a US physician who’s trying to wrap his brain around the patient – physician relationship. The film is being presented at a US Public Health event later this year. I’ll be sure to share the link.

Trust is one of the themes that has come up in several interviews that he’s had with both patients [aka: healthcare consumers] and professionals. Reportedly, no one knows who to trust when it comes to healthcare.

Trust has been eroded in both Canada and the US but for slightly different reasons. 

In Canada, the lack of choice and ability to actively participate in treatment decisions is eroding patient trust. Canadian physicians have no financial incentive to invest the extra time needed to educate their patients. 

In the US, the lack of pricing information and network participation is eroding patient trust. American physicians need to educate and almost sell their patient on their plan but patient trust has been undermined with various out-of-network and billing strategies.

When I ask people if the 80/20 rule [80% right thing done] applies in healthcare – most don’t agree. The responses are pretty dismal.

Trust is clearly a problem. Transparency will help to re-establish trust.

Progress

After 20 years of talking about consumerism in healthcare it’s easy to loose site of progress made and the benefits realized.

I spoke with an executive of Infoway yesterday and realized that Canada and the US are in much the same spot.

EHRs have for the most part have been purchased and implemented across the US and Canada. It’s taken longer than most of us in the industry expected. There have been a lot of mistakes made, lessons learned and yes – successes!

One thing that I really enjoyed is reading are the benefit studies done in Canada that highlight how the EHRs and other solutions have reduced the number of redundant tests, negative drug interactions, ER visits and admits.

Professionals in both countries are tasked with doing more with less. However, both countries are still struggling to get the financial incentives right to improve access and outcomes.

The US is shifting to more risk based models to reduce over utilization and improve outcomes. While in Canada, they need incentives to increase thru put and reduce the waiting times for non-emergent services.

The engaged consumer is the answer to both challenges. The problem is the word consumer doesn’t resonate with Americans or Canadians in the context of healthcare.

Triple Aim

The Canadian healthcare system is undergoing a similar digital transformation as the US.

Even though the healthcare systems are different in how they are financed, the triple aim of the transformation is for the most part the same.

The triple aim:

1/ Enhance the patient experience

2/ Reduce the cost of care

3/ Increase population health

A couple of differences to note:

1/ Patient vs. Consumer experience: The US has been trying to engage patients in consumer type behavior to help lower the cost of care. The jury is out on whether it’s having the intended effect or not. However, the word consumer resonates even less in a Canadian healthcare context even though many also have private insurance and pay some healthcare costs out-of-pocket.

2/ Clinical experience and productivity: The 4th aim in Canada whether official or not, is about making things easier for clinicians in order to utilize their time effectively and to reduce the risk of errors. Given the number of reported issues with EHRs and physician burnout, most US physicians would likely sign on to that aim too.

Regardless of country, it’s hard to manage risk in large scale transformations without stifling innovation. There are differences in how the risk is being mitigated and managed. I will touch on that too.

2020 Reform

Americans have a huge opportunity to get healthcare right in 2020.

The current system is broken. Access is limited by the lack of coverage and/or the cost of healthcare.

Medicare for All would make healthcare more accessible to all American even though access has yet to be defined in terms of who and what.

Getting who and what right is the first opportunity. If the benefits are too rich, the system will become unsustainable. Reportedly, Canada is spending 60% of all tax dollars on healthcare and have reached their maximum budget. They too are trying to address the rising cost with the triple aim.

The Republican concerns are real if other measures are not taken to curb the cost of healthcare.

Expanding access helps reduce the cost/person if people use the system to better manage their health and thereby reduce the need for expensive medical intervention.

For the theory to work:

1/ Self-Care: Americans need to take a more active role in managing their health and wellbeing.

2/ Primary Care: PCPs need to engage as health coaches rather than just as gatekeepers to specialists and pharmaceuticals.

3/ Coverage: Insurers need to cover self-care apps + devices.

The opportunity in 2020 is to present a new system that focuses on health and cares for the sick when needed.

Risk Pools

Risk pools are a powerful tool but they have been incorrectly within the healthcare system.

Risk Pools are a way for insurers to share the medical responsibility and financial risk with healthcare providers for managing a defined patient population. It rarely goes well.

Providers have a few big issues:

1. Insurers have premiums and investment vehicles to absorb risk pool loses. The risk pool is a limited amount of money with no means to increase the available funds. Providers end up rationing care.

2. Managing the risk pool is about predicting future medical events. The technology and methods providers use are getting better but still pretty limited.

3. The conversation between doctors and patients is changing. Patients are more informed of experimental therapies. Telling a patient NO when there is even a remote shot of something working would be tough for someone who is invested in the relationship.

Given that many insurers are becoming provider organization offering health coaching and preventative care, risk pools would be better used between the government and insurers as a way to incentivize them to keep people healthy.

The government is also better positioned to improve access by providing the Stop Loss insurance for patients with genetic issues.

Digital Transformation

The Canadian healthcare system is undergoing a similar digital transformation as the US.

Even though the healthcare systems are different in how they are financed, the triple aim of the transformation is for the most part the same.

The triple aim:

1/ Enhance the patient experience

2/ Reduce the cost of care

3/ Increase population health

A couple of differences to note:

1/ Patient vs. Consumer experience: The US has been trying to engage patients in consumer type behavior to help lower the cost of care. The jury is out on whether it’s having the intended effect or not. However, the word consumer resonates even less in a Canadian healthcare context even though many also have private insurance and pay some healthcare costs out-of-pocket.

2/ Clinical experience and productivity: The 4th aim in Canada whether official or not, is about making things easier for clinicians in order to utilize their time effectively and to reduce the risk of errors. Given the number of reported issues with EHRs and physician burnout, most US physicians would likely sign on to that aim.

Regardless of country, it’s hard to manage risk in large scale transformations without stifling innovation. There are differences in how the risk is being mitigated and managed. I’ll touch on that next.

Now – Near – Far

Now – Near – Far is a strategic framework that some executives of legacy healthcare systems are using now.

The framework was developed by James Hackett, CEO of Ford to assemble and align the resources needed to deal with disruptive market forces.

1. Now – Assembling and aligning resources for the Far.

2. Near – Executing on the strategic plan in a way that continuously meets the expectations and needs of patients.

3. Far – Imagining who your patients are, what they will need, what they will expect and how you can serve them.

The problem for some executives is that they are not thinking about the Far and may in fact be brushing it off as something they have seen before. However, the consolidation and emerging technology will eventually result in disruption to the status quo.

The threat for the legacy healthcare systems is the vertical consolidation of outpatient providers and insurers. The resources of the combined entity and the lucrative services provided will make them hard to beat.

Uber didn’t start with Pool. Uber started with a resource some people already used and made it easier to use. Then they offered cheaper options to capture more marketshare.

If something sounds too crazy to work. Don’t brush it off. Think about the possibility.

Health + Healthcare

Is health a personal choice or is there a role for physicians?

A friend recently said to me that the best thing a General Practitioner [GP] could do is write a referral to a specialist. He’s not in healthcare so I had to ask whether he thought GPs should help keep people healthy. He said no. Health is a personal choice.

Are GPs limited in what they can/should do for us by our limited expectations of them? Has the healthcare system trained people to have limited expectations? Or are GPs truly limited in their scope of work?

This conversation relates to another recent conversation with a dialysis nurse as well as our post on complimentary care providers. The dialysis nurse uses a GP that works as a complimentary care provider similar to a naturopathic doctor that helps assess among other things hormones and vitamin deficiencies that affect sleep, weight, mood etc.

The work of a complimentary care providers extend our ability to live healthy lives but few people know about them or know what they can do. Why?

The problem is that complimentary care providers are typically not integrated into the healthcare system and coverage is limited.

Apparently when they are integrated, GPs get the benefit of seeing what’s done and why. They get the full scope of the patient’s care. Patients get comprehensive care that helps them live healthier.