Tuesday, August 26, 2008

Systems Integration

With so much going on, I was surprised that I spent quite a bit of time thinking about a series of questions a writer posed about integrating health care information systems. I think I did this because I believe that the very definition of a "system" more or less dictates the outcomes producting the system and, in my mind, asking "are your current systems integrated?" is not as important as asking "do you know what information sources you must emphasize and integrate to improve health care?" One can either design for the last conflict, or try to anticipate the future and built towards what one knows must be achieved. I have always favored the latter approach.

Effective use of Information is the life blood of health care. Such integration affords greater quality of service, greater economic returns, and - in some instances - may literally save lives. The purpose of integration, therefore, extends beyond short-term efficiency and will either enable or constrain the evolution of a business.

To address any question of integration, health care executives must make assumptions about the very nature of their organization. When one says X is not integrated with Y (or X is integrated with Y) one states that somehow both X and Y are important to the business. When one has systems or information sources that are not even included in the assumptions, one is saying that these systems or information sources are not core to the business. If I say “it never occurred to me to think about integrating A with my integrated X and Y” one is saying either that such integration does not meet business objectives or is not even considered central to the core mission of the business.

So the right questions are not just : Are you integrating your current systems but also “are you developing a road map to integration or coordination of information sources that will improve your short-term prospects and position your organization for leadership in a wildly disruptive and chaotic environment? Integrating the right things propels an organization into a whole new level of business.

One need look only at organizations like Wal-Mart or Amazon to see how systems integration support market dominance. Integrating the wrong things may actually anchor one in the past and accelerate organizational demise.

Think of Clayton Christensen’s “Innovator’s Dilemma.” In this book he noted that the makers of the steam shovel knew about the back hoe, but they were so wedded to their steam shovels that they just couldn’t envision this new market. Similarly, most makers of main frame computers knew as much about early personal computers as those who built them, but they just couldn’t see how focusing on these disruptive technologies could possibly be the best use of their time as their margins were shrinking and their margins declining.

Health care plan executives need to approach their integration strategies to make sure they are answering the right business questions. They need to remember that the last steam locomotive ever built was no doubt one of the very best steam locomotives, but that the market has moved on.

The same issues face health care. Consumers, frustrated with the fragmentation and complexity of the health care system and fairly oblivious to its costs, are taking power - through informal support groups, through new means of care delivery, and through a new generation of personal health records and systems. Health care executives would be wise to try to understand this rising tide.

It appears that even within relatively well-defined boundaries, health care executives often believe that their own information technology houses are not in order. One must be sympathetic. The growing and increasingly absurd degree of coding complexity, regulatory confusion, and changing policy directions make integration of complex systems challenging. Still, given rising costs and the public perception that health plans and other intermediaries are doing very well, executives should be prepared to face a degree of unprecedented public accountability. Employers and individuals should, rightly ask, “if you don’t even have your own houses in order and running efficiently, why should I allow you stewardship over my health care dollars? Why, indeed, should you be in business at all?”

There are answers.

When I was employed by a large company in the health benefits sector that had acquired several other firms (each with its own free-standing information system), our visionary CEO tied a significant fraction of the bonus for every individual to achievement of systems integration targets. His claim was that everyone - in one way or another - could make life better or worse for our IT staff, and if we made it worse, the company would suffer. He recognized that until we got our own IT house in order, our customers would be confused, our employees would be frustrated, and our shareholders would not realize the potential of their investments. His strategy worked.

Other data suggest some integration with external partners or within their own family of companies. In addition, wise executives are uncertain which alignments made sense in this changing world. This explains the reticence to embrace new technologies, be they health information exchanges, personal health records, or other emerging approaches to health information management.

But the reality is this. As more and more health expenses are returned into the hands of consumers and as more complex mechanisms are required to extend coverage to more (or all) Americans and to cushion the impact of catastrophic illness, health care executives simply must try to understand that their organizations are only a part of the overall information flow affecting the lives of Americans. They don’t “own the health information game” but instead must work with others more effectively.

Abandoning a paternalistic approach - particularly if such an approach has been associated with short-term financial success - is not for the feint-of-heart. But a reformulation is as essential to these executives as it is to travel agents facing an emerging Internet or retailers facing Wal-Mart. Things change, and knowing how to change is a skill critical to success if not survival itself.

I am sympathetic with those who face integration challenges. Particularly in a field where billing complexity and reimbursement methods have never been stable and are likely to change radically in the years ahead, it is difficult to commit to 5-year plans where the regulatory and financial environment is at best seen only on a two-year horizon.

So at times it is far wiser to know what systems not to integrate, what systems to radically redefine, and what system to phase out. Simple integration of current systems could actually make things worse by making a broken system only break more efficiently. To paraphrase Mayor Richard Daleys’s comments 40 years ago during the Chicago Democratic Convention: “The police are not here to create disorder, they are here to preserve disorder.”

This is precisely the dilemma faced by health care executives. How do they balance IT investments among: systems that may “preserve disorder” and increase short-term operational margins; new systems that may attenuate disorder at the expense of short-term margins and that are not currently associated with a undeniable strategic advantage; entirely new relationships focused on the individual consumer and provider that both pose grave threats to current business models but significant opportunities if the world is changing as rapidly as many believe.

Thursday, August 7, 2008

Rules Doctors Need to Know

In the August 7 on-line version of the New York Time, Tara Parker-Pope contributes an article entitled "Six Rules Doctors Need to Know." She credits the source as Dr. Robert Lamberts. His blog, Musings of a Distractible Mind will not doubt be overwhelmed, but it's worth a look.
Having spent the last two weeks both in the aether of Washington and in the trenches of New York City, I find the article grounding not just with respect to its resonance with "consumer" discontent but equally as a guide for the very "why" of health care policy. It's not about white papers and legislative mark-ups, it's about people.

Here are his six rules. They are posted only as a teaser to guide the reader to the primary and secondary sources.

Rule 1: They don’t want to be at your office.
Rule 2: They have a reason to be at your office.
Rule 3: They feel what they feel.
Rule 4: They don’t want to look stupid.
Rule 5: They pay for a plan.
Rule 6: The visit is about them.

This posting has generated enormous response both in the addition of more "rules" as well as in commentary on the existing six rules. Most, this writer would argue, apply equally well to the "why" of policy more broadly. In my revision, I change the "they" to "we" since it's the "we" who are beneficiaries.

Rule 1: We don’t want policies and rules until we need them. Lambert points out that patients don't work in the office and most find the experience unnerving. They are, quite often, "naked" to the world when in the office. Ditto for policy makers and those who serve the "system." Lambert says the key to success in practice is "compassion." When was the last time one felt this in a back office or a hearing room?

Rule 2: We have reasons to want our health care system to work. No one wants to go to a health care facility. No one wants to have to think about progressive intermittent frailty, economic catastrophe from health care costs, cancer, heart disease, or the curse of obesity. Yet they are somewhere in everyone's minds. This observation may help focus policy-makers. As Lambert says: "On every visit I try to identify the real reason (or the real fear) that brings them to see me."

Rule 3: We feel what we feel. If in the public eye things don't make sense or one feels one is not being served, it's the responsibility of those serving to try even harder. As Lamert says, "you have to trust your patient...only the really crazy patients up symptoms."

Rule 4: We don’t don’t want to look stupid. Dr. Lamberts describes this from the perspective of the patient who is viewed as over-reacting. I would phrase this from the perspective of an individual seeking answers and and finding acronyms. Just try to understand the long-term care you or your loved ones need. Explain CHHAs, NORCs, SNFs, and the many other acronyms and terms designed, one imagines, to evade actually solving human problems. Acronyms are a symptom of unnecessary complexity. Their use promotes the degradation of the "lay public" and further isolates the voter from those charged to execute in the political realm. Request to those who work in government: successful candidates (from any party), don't use acronyms; neither should you!

Rule 5: We pay for a plan. We don't pay for orders and rules without a rationale that makes sense to us as tax payers and as individuals who will place our lives in the hands of the health care system policy creates. How well does our system actually prepare a plan to help someone adhere to medications and change behaviors rather than just drop the whole thing into the lap of the individual? How well do the components of our system work together on behalf of the individual? Sadly, we know the answer to this question; We should not feel proud.

Rule 6: Policies are about "us" - the beneficiaries - and the services we need; they are not about the policy-makers, lobbyists, health plays, employers, or other intermediaries.

Sunday, August 3, 2008

Governor Phil Bredesen: Three Health Care Reform Principle

In a July 31, 2008 blog posting entitled "Think Gas Prices Are High? Watch Out For Health Care," Governor Phil Bredesen outlines three principles for "Americans of many different political stripes [who] are ready to stop tinkering and instead devise a fresh and national solution to our health-care challenges."
Summarizing the three principles:

Principle 1: Incentives.

"The first principle is to once and for all fix the incentives.....One way to start would be to develop a national standard for what constitutes optimum quality health care in treating some of the more common and expensive diseases: diabetes and various forms of heart disease, for example. With a legally sanctioned standard, payments to providers could be revolutionized to pay for high quality and value — not just quantity."

Principle 2: An Rx for everyone
The Governor argues that we need to "build a solution good enough for all Americans." He cites as examples Social Security or Medicare and contrasts these with the "patchwork and means-tested government programs" that genearally don't "enjoy broad public and political support." He points out that this is not equivalent to "government largesse" but instead should be a benefit "earned by and owned by every American." This is a "national health care solution."

Principle 3: Incremental change
The Governor argues for "incremental change" and argues that one first step "might be federal underwriting of the costs of some of the most expensive diseases..... By insuring some of these costs, we could quickly transition our nation to managing many diseases in organized systems of care and paying for quality and outcomes, not procedures and pills."

These are some tough challenges but carry some popular, consumer-focused concerns. They could be used to tackle some of the big challenges (although all such plans to cover one or another disorder risk lobbying by many special interests). They require a radically different approach to managing the health information that individuals and their care providers need. They require a new view of quality based on meaningful metrics and not diagnostic and procedural claims along.

Governor Bredesen's "three principle" principle.
This is not the first time our Governor has boiled down complex issues into a short list of guiding principles. Three seems to be a magic number.

Take, for example, the three ideas he promoted in his HIMSS keynote of 2007. Paraphrasing his three ideas:
  1. Build version 1.0 first. He commented on the complexity and broad approach without establishing early wins.
  2. Focus on an achievable goal with broad implications. He mentioned e-prescribing and medication management as issues that affect nearly everyone. (Indeed, over year later, arguably the incredible progress that has been made through adoption and the merger of SureScripts and RxHub are the result of industry and congressional action more than emphasis by NHIN.
  3. Focus on adoption. He argued that attenion should be paid on how technologies should be focused on providing new value to providers and patients in "average" communities and not the more advanced and early adopters of technology innovation.
Governor Bredesen gave another three useful principles in a Democratic respose to a Saturday morning presidential radio address on June 11, 2005. Entitled Medicaid 2.0, the address, focused on three principles that are consistent with his most recent blog posting and should reassure those who think a comprehensive approach necessarily means government spending run amok. His principles are:
  1. Everybody pays something. Using the same "shopping in the store" metaphor for moral hazard mentioned in his more recent July 31 posting, the Governor said that "until everyone has a little skin in the game, the system will continue to be inefficient. "
  2. Pay for the important things first. Using acid reflux as an example of what not to pay for, the Governor said "Medicaid 2.0 needs to pare down what it pays for so that everyone has access to basic health care before we bring in the fancy trimmings." Again, looking from the perspective of a health care executive, his most recent address focuses on high overall spending conditions like diabetes and heart disease. (Eight years ago, this writer learned that from a pharmacy benefits management perspective, high spend drugs where not always for high-impact health conditions: non-sedating antihistamines and acid reflux medication topped the list.)
  3. Pay for what works. Although the Governor noted in 2005 the growth in "me too" drugs, the notion of "paing for what works" is very much in the national spotlight and the topic of much discussion under the rubrick of "comparative effectiveness." For more information, refer to recent Roundtable on Comparative Effectiveness activities of the Institute of Medicine.
Lists of three really work - particularly if over time the lists form an internally consistent pattern and drive towards an important goal. This writer is aware of three lists from one enlightened governor: one list focused on health care reform priorities and methods, a second on information technology, and a third paralleling the first and focusing on Medicaid. Some of the entries on the list can be achieved within a year (effective e-prescribing and medication management, for example). Others will take time and depend greatly innovations in quality, payment reform, and the evidentiary basis for care.

The challenge I believe, is to turn a short and easily understood set of guiding principles into an effective plan of action that demonstrates clear progress for the average American. The current fragmented approach drives well-intentioned individuals and organizations into spending an inordinate amount of their resources navigating a bureaucracy made unmanageable by four decades of modification. There is little value in uneccesary complexity. Maybe its time to "think in threes."