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Monday, April 9, 2012

Barriers and Brickbats and Opportunities


From a comment posted on a LinkedIn Discussion Board thread "Meaningful" Use under attack:
"[A]lmost all HIT vendors cater to government rather than to those who must purchase their products, the Soviet-style HIT mandate predictably eliminated the natural cleansing effect of free market competition almost a decade ago."
Really? Then how do we explain away the nearly 2,000 ONC/CHPL Certified EHR outpatient / inpatient / complete / modular HIT products to date?

None of which is to argue unreflectively that the feds (or the chimerical "free market"**) have gotten it all right with respect to health IT.
** Beyond tribal warlord societies there's no such thing as "free markets." In the end, human socioeconomic affairs get "regulated" independent of the transient or entrenched microeconomic transactional actors one way or another when push comes to shove (which is to say, routinely). Choose your antipathy.
"If there were only one man in the world, he would have a lot of problems, but none of them would be legal ones. Add a second inhabitant, and we have the possibility of conflict. Both of us try to pick the same apple from the same branch. I track the deer I wounded only to find that you have killed it, butchered it, and are in the process of cooking and eating it.
The obvious solution is violence. It is not a very good solution; if we employ it, our little world may shrink back down to one person, or perhaps none. A better solution, one that all known human societies have found, is a system of legal rules explicit or implicit, some reasonably peaceful way of determining, when desires conflict, who gets to do what and what happens if he doesn't."
- David Friedman, Law's Order (1999)
Also, with respect to "markets," recall my June 2011 post "Use Case," which cites medical economist J.D. Kleinke at some length.
HIT market failure. The underlying cause of Joe’s death is health information technology (HIT) market failure. If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.
Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.
This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit.
The positive externalities of an HIT system approaching the functionality of our consumer finance IT system include reduction of medical errors like the one that killed Joe Wilson; elimination of tens of thousands of redundant and expensive tests, procedures, and medications, many of which are not only wasteful but harmful; and the coordination and consistency of medical care in ways only promised by the theoretical version of managed care. These public health benefits are well beyond the reach of a health care system characterized by the complexities of medicine and conflicts of multiple parties working at economic cross-purposes. They are trapped outside the economic equation, positive externalities of a stubbornly fee-for-service health care system that inadvertently rewards inefficiency, redundancy, excessive treatment, and rework...
Health Care’s Blue Screen Of Death: Reboot Or Reform?
The compulsion today is to find the elusive “business case” for health care IT. Legions of IT vendors and consulting companies have struggled to cobble together “the ROI” (consultantspeak for “return on investment”) to prove that an individual health care organization would benefit by investing in better IT and that the failure to date has been merely a cultural problem on the demand side (“the doctors won’t use computers”) or a sales problem on the supply side (“it’s all vaporware”). These objections are hardly sufficient to stop a force as revolutionary as IT. The practical reality is that the typical ROI is modest at best, ephemeral for most, and attainable only well past its investment horizon—a dressed-up way of saying that it exceeds the political capital of its current CEO and CIO. If there were a strong business case for a health care organization to break from the pack and build out a twenty-first-century IT system, we would have no need for this paper—or, for that matter, this entire issue of Health Affairs. If the health care IT market worked, it would have worked by now.
"If the health care IT market worked, it would have worked by now."

I feel the start of a long post coming on. Stay tuned...
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UPDATE: from Modernhealthcare.com

Nervous RECs
Despite centers' success, sustainability still an issue
In a sense, the federally funded Health Information Technology Regional Extension Centers Program is just a baby. It turned 2 years old this year.  
On the other hand, the RECs (pronounced “wrecks”) may have half of their programmatic lives already behind them, with their survival beyond four years still very much in doubt.
After six rounds of funding, the Office of the National Coordinator for Health Information Technology at HHS has allocated $721 million for the REC program, which was created under the American Recovery and Reinvestment Act of 2009 and modeled after the 98-year-old cooperative extension service in agriculture.
Unlike the ag service, which receives annual appropriations, including $475 million this year, the health IT extension program is funded for only four years. After that, each REC must financially fend for itself... 
...If physicians are compelled to pay full price for the things RECs now provide, “We're going to have a huge slow-down going forward,” Arrowsmith says. “It's just inevitable. Our services are so subsidized. Especially in primary care, they're just not able to pay.”
Nice to know that there are people out there arguing for the REC program. And, we're not pronounced "wrecks," we're R-EEE-CEEEs.

"WE'RE NOW A 'START-UP'."


Such was the recent bubbly executive exhortation at our QIO/REC/HIE shop. With REC sustainability dicey, we're pretty much betting the Farm on our new HIE (HealtHIE Nevada), and are now urged to don an "entrepreneurial" mindset toward making it sustainable.

A recent post on The Health Care Blog pointed me to the Effectuation.org website, which posits some intrguing assertions worthy of deeper study.
Effectuation is a logic of entrepreneurial expertise. What makes great entrepreneurs isn’t genetic or personality traits, risk-seeking behavior, money, or unique vision. Effectuation research has found that there is a science to entrepreneurship and that great entrepreneurs across industries, geographies, and time use a common logic, or thinking process, to solve entrepreneurial problems. Effectuation is a logic of entrepreneurial expertise that both novice and experienced entrepreneurs can use in the highly unpredictable start-up phase of a venture to reduce failure costs for the entrepreneur...
Context. Effectuation is an idea born of a unique look at an age old problem – what makes entrepreneurs entrepreneurial? By the late 1990’s this question had been debated for decades by both academic researchers and practitioners of entrepreneurship with little success. The main focus of academic research had been on two theories: 1) that entrepreneurship either a genetic or acquired personality trait or psychological condition (risk seeking) and 2) that entrepreneurs took advantage of opportunities that were created by inefficient market forces, regulation, and scientific breakthroughs. Even if science had supported these theories, they were of no practical use to the entrepreneur who was starting his or her business.
Further, dozens of entrepreneurs publish memoirs and “how-to” books on entrepreneurship every year. These are based on the unique experiences of the individual entrepreneur (which is good) but aren’t a) backed up with science or b) universally applicable.
No one had gotten the truly unique characteristics, habits, and behaviors of the species entrepreneur.
The Worldview. Expert entrepreneurs believe that the future is shaped by people. They believe that if they can make the future happen, they don’t need to worry about predicting the future, determining perfect timing to start, or finding the optimal opportunity. Sarasvathy calls this “effectual logic” which sits opposed to “causal logic” taught to managers in more certain (or predictable) circumstances.
Effectuation vs. Causation. Aspiring entrepreneurs in MBA classrooms have long been taught the principles and tools of causal reasoning—the exact inverse of the effectual reasoning that drives entrepreneurial success. Using causal reasoning, one begins with a specific goal and a given set of means for reaching it. Using effectual reasoning, one starts with only a set of means; in the process of deploying them, goals gradually emerge.
Causation. The focus is on achieving a desired goal through a specific set of given means. Causation invokes search and select tactics and under-lies most good management theories. Causal thinkers believe that “If I can predict the future, I can control it.”
Effectuation. The focus is on using a set of evolving means to achieve new and different goals. Effectuation evokes creative and transformative tactics. Effectual logic is the name given to heuristics used by expert entrepreneurs in new venture creation. Effectual thinkers believe that “If I can control the future, I do not need to predict it.”
Effectuation consists of a unique world view and 4 principles. These 5 elements are core to using the “effectual cycle” as a venture develops.
The Principles
Bird in Hand Principle – Start with your means. Don’t wait for the perfect opportunity. Start taking action, based on what you have readily available: who you are, what you know, and who you know.
Affordable Loss Principle – Set affordable loss. Evaluate opportunities based on whether the downside is acceptable, rather than on the attractiveness of the predicted upside.
Lemonade Principle – Leverage contingencies. Embrace surprises that arise from uncertain situations, remaining flexible rather than tethered to existing goals.
Crazy-Quilt Principle – Form partnerships. Form partnerships with people and organizations willing to make a real commitment to jointly creating the future—product, firm, market—with you. Don’t worry so much about competitive analysesand strategic planning.

It will be interesting to see if we can make the transition from "managerial thinking," which is in fact our long-standing QIO (and now REC) culture. We have some serious internal barriers to surmount. Not sure that we are adequately "fleet of foot" and otherwise amenable to this type of radical transformation (sometimes it seems that "transparency" seems to be disturbingly moving the other way toward FUD inside our walls) .

Having said that, the jury is still out for me on the underpinnings of this "effectual action" proposition. Do the entrepreneurial winners get to "write the history" (akin to "publication bias")? Are these SEA people too just selling book and conferences?

More study needed.


UPDATE

From Jeff Bussgang's Seeing Both Sides blog post "Signal to Noise - How to Cut Through the Clutter"-

So how do the best entrepreneurs cut through the clutter and distinguish themselves and their companies?  How can they grab the attention of customers, partners and investors in an era of overwhelming, defocusing flow?  Here are the top five behaviors I have observed in entrepreneurs who seem to be unaffected by the amount of static around them and are able to stand out amidst the noise:
  1. Put on your blinders. I've noticed that many great entrepreneurs have the ability to ignore the inputs around them, even (gasp) to ignore their inbox.  Some of their friends may brag about achieving "zero inbox" nirvana (i.e., having read and processed every email that comes in), but the great entrepreneurs I work with actually actively strive to avoid having a "zero inbox".  Instead, they consciously block out reacting to inputs and focus their proactive energy on their priorities.  Speaking of priorities...
  2. Focus relentlessly on the customer value proposition. The entrepreneurs I love working with wake up every morning thinking about their customer.  There are so many distractions when you are building a start-up, but if you solely focus on your customer and addressing their pain point every day, you will be in a strong position.  One of my portfolio company CEOs sometimes looks bored during our board meetings when we cover topics like finances, operating metrics and recruiting.  But when we get to the portion of the meeting where we talk about his customer, he totally lights up and is full of war stories and compelling ideas.  You obviously can't solely focus on the customer value proposition, because you also can't run out of cash, ignore competition and neglect to build a world-class team.  But that leads to the next characteristic...
  3. Focus on very few things. Great entrepreneurs are brilliant at keeping things very simple and focusing only on a few of the highest-priority, highest-impact items.  I learned this lesson from a mentor early in my professional career.  There is something to the "power of three" (keep your mind focused on only three goals at any given time) or even the "power of one".  I try to maintain the discipline of writing down my three summary goals for the year on one-page and keep it in my folder at all times, pulling it out every few weeks and reminding myself of them.  The priorities may change, but the discipline of focusing on very few things should never change.
  4. Avoid bright, shiny objects. A corollary to focusing on very few things is that you should actively avoid "bright shiny object syndrome".  This is the well-known start-up disease of entrepreneurs getting distracted by the latest interesting new idea or opportunity.  One of entrepreneur friend of mine is susceptible to this - his last three meetings were the most important ones in shaping his thinking and setting his priorities and he finds it hard to ignore the inevitable distractions that comes out of a positive partner conversation.
  5. Be a contrarian. Contrarian thinkers stand out from the crowd, plain and simple.  The start-up world tends to encourage a form of groupthink.  There emerges a conventional wisdom in the blogosphere that is propagated and validated through the various social channels.  But great entrepreneurs relish the opportunity to challenge the status quo and conventional wisdom and go against the grain. The best ones develop that contrarian point of view so fully that, over time, it wins out and itself becomes the new conventional wisdom.
Interesting. Good stuff. Mulling over the triangulation here.
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BACK TO MU:
SUCCESSFUL ATTESTATION TIPS

4 MU Tips from a Multispecialty Practice
Carrie Vaughan, for HealthLeaders Media, April 6, 2012
This article appears in the April, 2012 issue of The Doctor's Office.
For the most part, the first group of providers to qualify for Stage 1 of the meaningful use regulations in 2011—and deposit incentive checks in the bank—were early adopters of electronic health records such as Old Hook Medical Associates, LLC in Emerson, NJ, a multispecialty practice that implemented its EHR in 2007.

OHMA has one location and 20 providers, including full- and part-time positions and nurse practitioners. It began using a commercial EHR solution in 2007. "That was essentially our first real EHR," says Edward Gold, MD, president of OHMA, as well as an oncologist and hematologist. "We had been using a medical manager product and were using some of the EMR capabilities that it had, which were limited. But we really weren't fully electronic until 2007."
OHMA began its 90-day meaningful use ­attestation period on January 1, 2011. It submitted its data on April 19, 2011, qualified for everything it submitted, and received a $180,000 incentive payment in May 2011.
The practice submitted data for 10 physicians. OHMA has some part-time physicians who didn't qualify because they only work a couple of days per week and OHMA isn't their primary practice, Gold explained. 
He offers the following advice to practices considering MU attestation: 
1. Don't accept pushback.
Gold says OHMA made a corporate decision to switch from paper to EHRs and didn't accept opposition from its physicians. As such, the physicians didn't get to choose whether to use the technology...
"We said, 'Okay, if you want the chart, it will be in the medical records room but it won't be delivered to your desk anymore"...
2. Adopt the system, whichever you choose, wholeheartedly.
OHMA uses every capability its EHR system offers, including the health maintenance portion, says Gold. "We went into it with both feet," he says. "The software is designed to be used as a whole unit. While you can pick and choose what you want to use with some of these programs, if you want to get the most out of it, you have to use the full functionality of the product—and that goes for any EHR product."...

3. If also pursuing PCMH designation, combine efforts.
About one and a half years before pursuing meaningful use, OHMA made the decision to become a patient-centered medical home. OHMA was seeking a level-three PCMH qualification, and through that process, fulfilled many of the criteria for meaningful use—such as coordinating care, setting up a patient portal, and using e-prescriptions, says Gold.
In addition, the practice was already using the health management aspect of its EHR, which provides recommendations, such as tests or screenings, for patients based on age or disease, as part of its effort to achieve the PCMH designation. OHMA was using practice analytics to identify diabetic patients with high blood sugar levels, for example, and it had processes in place for a nurse to follow up with those patients.

Because OHMA had these processes and the capability to collect data, "it became fairly easy to meet the level one meaningful use criteria," Gold says...

4. Double the estimated training time.
Like any software product, whether it's an EHR or Microsoft Excel, the more familiar you are with the ins and outs of the software, the easier it is to get things done, says Gold.  The problem is that physicians are very busy and don't have a lot of patience, he says. "[Physicians] don't want to spend the time necessary to learn the product properly so that they can get the results that they want. They are used to telling an office manager to do this and it gets done," Gold says...
Physician practices need to spend time on implementation. Without a robust training plan, you can't succeed, says Gold. The challenge today is that "it is such a busy field right now with people buying products that the [vendor] companies are stressed to get [providers] implemented and get the training done," he says.
"Some [vendors] will say, 'We'll have you trained in a day and half—up and running—and you'll be good.' That is not true…whatever they tell you you need in training, double it."

Great advice. Consider my 2nd REC blog post nearly 2 years ago.


The cut-to-the-chase core take-away from this very worthy book is pretty straightforward:
  1. The truly difficult work begins after EHR go-live implementation. This is NOT about "IT" per se;
  2. You simply must have HIT physician champions;
  3. And, you must devote extended post go-live resources to function-based training, delivered via simulators and Adult Learner modeled content -- i.e., constrained, didactic, classroom-based (and "train-the-trainer") methods simply do not suffice.
Anything less is a recipe for failure (regarding which they enumerate some painfully honest examples from within their own organization).
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MERE ROTE "TRAINING," 
OR INCULCATION OF CRITICAL THINKING?


This, from my Society, caught my eye recently.

Introduction
Statistics is inherently the broad science of obtaining information from data. Many have the opportunity to teach statistical tools, statistical concepts and statistical thinking. These opportunities arise in formal classroom environments as well as in informal one on one consulting situations. In reality, all who work in the field of statistics must be teachers to those around them, whether or not they teach formal classes. As teachers, we serve as catalysts to help people learn and develop their abilities to think statistically and maximize the information that they obtain from data. A common theme in statistics education is to shift the focus of teaching away from viewing statistics as a collection of tools (See for example Cobb (1992), Moore (1998)) and Garfield and Ben-Zvi (2008)). Rather statistics should be taught such that students have improved critical thinking skills or statistical reasoning abilities, meaning that they are better able to understand critical concepts related to data, variation and drawing conclusions from data. Statistical thinking, as defined by the ASQ Statistics Division (2011) falls within this category of critical thinking and reasoning skills. As a result, those who seek to teach concepts of statistical thinking must use teaching methods and techniques that correspond to the type of learning that must take place. Britz et al. (1997) gave an example of how to teach statistical thinking concepts. I illustrate here another teaching method, the Socratic Method, which I have successfully used in formal statistics training in academia and industry and in consulting situations to teach concepts related to statistical thinking. After describing the method, I’ll give an example of how to use the method to teach statistical thinking concepts related to Design of Experiments (DOE).
What is the Socratic Method?
The Socratic Method is named after the famous Greek philosopher, Socrates, who lived in the 5th Century BC. As we do not have any of his own writings, all of what we know about him comes from the writings of his students and contemporaries, Plato being the foremost of them. The writings of Plato depict Socrates as a man who continually questions individuals, thereby challenging their assumptions until at some point a logical fallacy is exposed in their thinking. This process of using a series of questions to guide the learner to a conclusion has come to be known as the Socratic Method. It can be thought of as a method of answering a question with a question.
It is a valuable approach to teaching because it shifts the focus away from rote memorization and mechanical calculations toward the development of critical thinking skills. I believe we need less teaching of statistical tools which can be handled ever more easily with computing power, and more teaching of appropriate use of statistical tools. While I was a student, one of my professors loved to quote a saying attributed to George Box, “Why do we aspire to be second-rate mathematicians when we could be first- rate scientists?” (Vining 2010, p. 135). This saying emphasizes how statistics is much more than just a collection of tools. To be a good practitioner of statistics, there are critical reasoning skills required to know how and when to use the tools. Along a similar vein, I would ask, why do we teach students to be second-rate calculators when we can teach them to be first-rate users of statistics?
When employing the Socratic Method, the teacher is not specifically trying to expose a flaw in the student’s thinking to then ridicule them, as Socrates was wont to do. Rather the teacher is challenging their assumptions and gut reactions. This challenging of assumptions helps the student to understand their own thought processes and forces them to explain why they think a particular way. Even when a strict form of the Socratic Method is not used by the teacher, it is the “questioning mode” that adds value and helps the students become more independent thinkers...
"...helps the students become more independent thinkers."

One would hope, academically speaking. But, Speaking Truth to Power on the job is frequently freighted with its own risks, given a particular organizational pecking order / power reality. Notwithstanding that I love this stuff on the merits, I have to wonder about its dispersive / deployment utility. In my experience, when you box people in Socratically, they tend to dismiss you summarily or via endless "yes, but..." (having adroitly avoided the inconvenient logic), declare "victory," and move on.

Which all goes to the Sperber / Mercier paper "Why Do Humans Reason?" (in my links column).
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4/12 UPDATE


Great, lengthy, detailed slide deck pdf. Link here.
Four Major Issues for the Court
Anti‐Injunction Act: Does the Anti‐Injunction Act prevent a court challenge regarding the individual mandate until a penalty/tax is actually paid?
Individual Mandate: Does Congress have the power under the Constitution to requiring nearly all individuals to purchase minimum health insurance coverage under threat of penalty?
Medicaid Expansion: Is ACA’s requirement that the states expand Medicaid eligibility unduly coercive in violation of principles of federalism in the Constitution?
Severability: If either the Individual Mandate or the Medicaid Expansions are found unconstitutional what provisions, if any, of ACA can remain as severable?
I've been aware of the implications for quite a while. There are a lot of improvement initiatives linked to the ACA. This deck is really worth your time.
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More to come...

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