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Saturday, June 16, 2012

ObamaScare Section 5405

"and other purposes."

"Facilitating Improvement in Primary Care: The Promise of Practice Coaching"

My friend Dr. Joe Fortuna, outgoing ASQ Health Care Division Chair, sent me a copy of the above-titled Issue Brief the other day. While I knew that "ACOs" and a raft of other "improvement/innovation" initiatives were authorized by the soon-to-be-SCOTUS-ajudged  PPACA (derisively, "ObamaCare"), this Section had escaped me.
Practice coaching in health care is rooted in the agricultural extension agent model of the early 20th century. In 1903, the U.S. Department of Agriculture started a program by which agricultural experts would visit farmers, develop ongoing collaborative relationships, suggest improvements, and facilitate the sharing of best practices. The program was highly successful as farmers, seeing the increased yields and profitability of early adopters, improved their agricultural methods. In 1914, Congress created the Agricultural Extension Service (AES)—now the Cooperative Extension Service—and, by 1920, 7,000 extension agents were working in almost every county of the nation.
Many primary care services in the United States are delivered by relatively small, independent private practices and community health centers lacking the robust quality improvement infrastructures found in hospitals and big medical groups. Just as small farmers were most in need of the kind of support provided by the AES, it is these smaller physician practices that are most in need of help. Donald Berwick, M.D., then president and CEO of the Institute for Healthcare Improvement, recognized this reality when he wrote in 2003 that “American health care could benefit greatly from the establishment by the federal government of a Health Care Extension Service modeled on the AES.” In 2009, physicians Kevin Grumbach, M.D., and James Mold, M.D., detailed how a health care cooperative extension service for primary care might look, with practice coaches serving as extension agents to spread the best practices of early adopters to primary care practices across the nation.
A year later, the Affordable Care Act of 2010 authorized creation of the Primary Care Extension Program along the lines proposed by Grumbach and Mold, and in 2011 the Agency for Healthcare Research and Quality—the agency charged with implementing the program—issued a call for proposals to award three states grants for primary care extension programs. Although Congress has not appropriated funds to implement the nationwide program, the many state and regional models of practice coaching being implemented—for example, by the Vermont Blueprint for Health, Colorado HealthTeamWorks, LA Net in Southern California, and federally funded regional extension centers promoting meaningful use of electronic health records [emphasis mine]—affirm the belief in many quarters that most practices cannot undertake needed transformation without such a mechanism in place.
Practice coaching can be viewed as analogous to self-management health coaching for patients. Coaching patients with chronic conditions means imparting patients with the knowledge, skills, and confidence to self-manage. Coaching does not do things for patients; it helps patients do things for themselves. The practice coach helps physicians and their staff gain knowledge and skills in the science of improvement so that they can continue to improve long after the coach is gone. Empowering practices to become their own agents of change is one of the features that distinguishes coaching from consulting...
Interesting. Two years ago RECs started out with all this noble rhetoric about helping "physicians and their staff gain knowledge and skills in the science of improvement...Empowering practices to become their own agents of change..."  -- and I am personally no exception, being a quarter century True Believer in QI; e.g., see my standard introductory workflow improvement deck (PDF) I use to try to sell the effort to small practice staffs. I am always frank to acknowledge that "if you burn up all of the MU incentive money in added labor cost resulting from more onerous workflows, what's the point?"

But, the boots-on-the-ground  REC technical assistance staffing reality largely dictated Milestone progress body counts.

So, today, we end up with stuff like this:

A Funny thing Happened on the way to Meaningful Use
Rob Lambert, MD
This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind. No, I didn’t stop thinking that EHR was a very powerful tool that could transform care. I didn’t pine for the days of paper charts (whatever they are). I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven’t. In fact, they’ve made things much worse...

...My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words: “meaningful use.” I am starting to fantasize about a life without it, and maybe even a life without anybody else’s definition of what the care I give should look like. I want to be a doctor.  I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?
Ouch. And, this doc is no Luddite crank. Read the entire post.

Also of late, apropos of the issue.

Unraveling the IT Productivity Paradox — Lessons for Health Care
Spencer S. Jones, Ph.D., Paul S. Heaton, Ph.D., Robert S. Rudin, Ph.D., and Eric C. Schneider, M.D.
N Engl J Med 2012; 366:2243-2245June 14, 2012

There is ongoing debate about the wisdom of the $27 billion federal investment driving the adoption of health information technology (IT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Proponents expect IT to catalyze the transformation of health care delivery in the United States from a fragmented cottage industry plagued by poor quality and high costs to a highly organized, integrated system that delivers high-quality care efficiently. Skeptics suggest that the productivity benefits of health IT have been overstated, arguing that it may create safety problems and could even increase costs...

New health IT systems risk failure if usability isn't carefully addressed. User-centered design calls for end users to be involved in every stage of product development. The principles of user-centered design have improved usability for many IT products. The merits of such design processes are illustrated by the evolution of “smartphones,” from their early monochromatic displays and clumsy thumb keyboards to today's high-definition touch screens that use the electrical properties of the human body to enhance responsiveness...

...The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests three lessons for physicians and health care leaders: invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT's use in health care.
Another good article.

So, where does all of this leave us?

Absent replenished funding from some source, RECs are effectively done next summer. As I've noted before, we are not funded for Stage 2 (which now doesn't ensue until 2014), and were I a 2011 Meaningful Use Attestor (Medicare EP), I'd have collected 87% of the total reimbursement potential ($38k/$44k) just for Stage One. OK, I'm trying to understand my ROI prospects for Stage Two here.

There are some looming barriers here, leaving aside the carping HIT critics (and I in no way mean to imply that Dr. Lambert is among them; he's one of the good guys). The brave, fashionable REC talk of "sustainability" these days has to leave one dubious.

I have made no secret of my frustration with this recent headline.

My comment?
I’d be interested in any initiatives aimed at “Positioning REC for Continued Success.” I have a concern that a brain drain may soon ensue.
Silencio. Zip, Zilch, Nada. Two years ago ASQ's Dr. Fortuna offered the good offices of the ASQ Health Care Division, pro bono, to ONC to help with in-the-trenches improvement efforts of the sort envisioned in the "practice coaching" and Primary Care Extension Centers concepts alluded to above. Those polite discussions went nowhere.

The need remains. The need goes beyond ONC being politically seen as a "success" in Secretary Sebelius's eyes.

Beneath the Jurassic DC Rain Forest Canopy that is HHS roam a number of territorial beasts of varying defensive perimeter ferocity: CMS, AHRQ, ONC among them. PPACA Section 5405 bestows upon AHRQ the authority to establish and administer "Primary Care Extension Centers." Yeah, that'd go over well in other Beltway shops.

Beyond turf contention considerations, and assuming PPACA survives the looming SCOTUS challenge decision (wholly or in pieces), I would think it to be an extreme long shot for 5405 initiatives to get publicly funded, given both the 2012 election year and the larger federal budget deficit problems that will await the next President and Congress.

But, again: the need remains.
Dr. Toussaint's new book sheds some useful light on addressing the need (it just came out on Kindle, so I can now more conveniently cite passages from it).

Change is bearing down fast on healthcare in the United States—not small change but a full overhaul of the system that will be as disruptive as it is inevitable because we can no longer afford to pay huge bills for substandard care.

As a doctor, a Chief Medical Officer and then CEO of major regional health system, I know that our biggest challenge is the immense waste in our care delivery system that causes poor quality and inflated costs. The magnitude of this opportunity is mind-boggling. The Institute of Healthcare Improvement reports that 30–50% of care delivery is wasteful, meaning that it is of no use to the patient. Translation: $750 billion per year could be saved if we get rid of the waste.

Around the country, various groups have been attacking the issues piecemeal. Several health systems have made great strides toward increasing healthcare quality and reducing medical harm, but are working in isolation and often end up struggling against a system that actually rewards waste and error. Meanwhile, the major proposals for healthcare reform focus on financial structures and money flow, on changing who will be insured, by what rules and by which intermediaries. These proposals do little more than shift around risk and create new layers of guidelines, rules, and laws while the root of the problem—quality—remains untouched. The largest piece of healthcare reform legislation passed in more than a half-century, the 2010 Affordable Care Act, bears an estimated cost of about $1 trillion over the next 10 years, but does not go far enough. We can improve upon it if employers, providers, patients, and governments work together to ensure better quality, affordable healthcare.

We need a healthcare system that focuses on healing, that encourages innovation without dictating how a patient receives care. This will require a systemic overhaul... (Kindle Locations 55-67).

First, we need to see. In order to build a true picture of any healthcare system, we must identify the data that accurately illustrate reality regarding quality and cost, and then publish that data in a way that people understand. When we achieve this type of transparency, everyone will have the same picture.

Next we must redesign the payment system, which is the tail wagging the healthcare dog in this country. Right now we pay for procedures, so Americans get more procedures and pay more for them than citizens of any other industrialized nation. What we really want to pay for is health and appropriate interventions to achieve ongoing health—a goal that can only be accomplished if we have adequate transparency in the system and can see what we are paying for and how much.

Finally, the true purpose of a meaningful redesign is to reorganize healthcare around the needs of the patient instead of the convenience of insurance companies or doctors. Better care for the patient is the real goal and, with every change, we must ask how it serves patient health. Without a healthier population receiving better care, any redesign is wasted effort (Kindle Locations 84-93).
Tall order. Noble and true sentiments. Below, toward the conclusion of the book:
ThedaCare’s decade of experiments with continuous improvement proved there was a minimum 30% waste in our healthcare processes. Often, the wasted time, energy, and materials in a process was closer to 50%. These experiments have been repeated in dozens of healthcare organizations in the United States, Canada, and elsewhere with the same results. 

The United States spends $2.5 trillion in healthcare every year. The 30-percent-waste in healthcare estimate is widely accepted. That means healthcare waste equals $750 billion every year. So, there is a lot of money in the margin. 

Organizations that aggressively remove waste and redesign care-delivery systems will be the ones able to pay physicians, nurses, and therapists better wages. (Likewise, healthcare professionals who take the most waste out of care processes will be highly prized.) In the end, the improvement-focused systems will be able to attract the brightest talent. 

Existing finance mechanisms and vertical silos, however, are deeply entrenched in our healthcare systems. Moving to new compensation techniques that support healthcare value will require some trial and error... (Kindle Locations 2017-2026). 

To find the most workable model, we need to return to the scientific method—observation, hypothesis, testing, and modification of hypothesis or action. Before one payment type will emerge as the clear winner, we need regional health systems to conduct experiments with global and bundled payment for health episodes, and shared savings models. Experiments need to begin now, with reports published in peer-reviewed journals, giving everyone in the medical community an opportunity to see the evidence and join the debate (Kindle Locations 2045-2048).
Continuing with the process improvement theme he proffered in "On The Mend," Dr. Toussaint again exhorts the utility of the lean model:
In a lean environment, physicians and staff use the scientific method to guide their work in the form of PDSA—plan, do, study, act. Instead of searching for a person to blame, they use PDSA to study the cause of error, devise a plan to correct the system—which is usually at the root of error—and then fix the process. This means that errors must be laid bare for everyone to see, as opposed to hidden. This is another type of transparency demanded in a lean environment. When everyone knows that errors exposed are actually opportunities to improve the system through PDSA instead of avenues to shame, people are less likely to hide their errors and compound problems (Kindle Locations 2058-2062).
Color me a believer. From one of my slide decks:

Notwithstanding the truth of all that, a respect for small practice barriers also required this slide in my deck.

"Staff ownership of Lean projects" -- in other words, the result of effective "Practice Coaching," 'eh?

Irrespective of what happens to ObamaScare this month (and Section 5405's "Primary Care Extension Program" proposal) or us RECs, the need will not go away, particularly within the small shop primary care setting -- places where time and margins are stretched so thin as to even make our offers of "free" federally underwritten assistance a tough sell. These are not clinics that are going to pay $125 - $200 per hour (or more) for consulting/"coaching" help.


WALTHAM, Mass.—It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

Even as consumer IT — word-processing programs, search engines, social networks, e-mail systems, mobile phones and apps, music players, gaming platforms — has become deeply integrated into the fabric of modern life, physicians find themselves locked into pre–Internet-era electronic health records (EHRs) that aspire to provide complete and specialized environments for diverse tasks. The federal push for health IT, spearheaded by the Office of the National Coordinator for Health Information Technology (ONC), establishes an information backbone for accountable care, patient safety, and health care reform. But we now need to take the next step: fitting EHRs into a dynamic, state-of-the-art, rapidly evolving information infrastructure — rather than jamming all health care processes and workflows into constrained EHR operating environments.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

Early health IT offerings were cutting-edge, but contemporary EHRs distinctly lag behind systems used in other fields. In 1966, members of Octo Barnett's laboratory at Massachusetts General Hospital invented a highly efficient programming language for the earliest EHRs; the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) partitioned precious computer memory so parsimoniously that with only 16 kilobytes, the earliest personal computers could run an EHR supporting multiple users. But nearly a half-century later, most EHR vendors not only have failed to innovate but don't even embrace existing modular architectures with interfaces that allow extension of product capabilities, innovative uses of data, and interoperation with other software...
...Loss of technological leadership reflects apathy and even opposition by EHR vendors to promoting liquidity of the data they collect. This attitude has thwarted medicine's decades-long quest for an electronic information infrastructure capable of providing a dynamic and longitudinal view of the health care of individuals and populations. EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician's information services department and often the specialized knowledge and cooperation of the vendor's technical teams. In reaction, scores of academic medical centers have exported data into a common open-source system where population-level analytics are managed outside the vendor, and results shared across sites...

Commercial EHRs evolved from practice-management (i.e., billing) systems, and in response to the patient-safety movement, vendors tacked on documentation modules and order entry for physicians. Since each EHR product has been built as an isolated silo, the market for any good innovation is fragmented. Additional problems arise when complex software that was never engineered adequately must be reimagined, reinvented, and reimplemented repeatedly...
...Health IT vendors should adapt modern technologies wherever possible. Clinicians choosing products in order to participate in the Medicare and Medicaid EHR Incentive Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation. New companies will offer bundled, best-of-breed, interoperable, substitutable technologies — several of which are being developed with ONC funding — that can be optimized for use in health care improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of “meaningful use,” signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.
One would hope. But, then again, transparency and vendor margin remain inversely correlated. And, it remains to be seen just how much more "ONC funding" will continue to flow (outside the Beltway, anyway). 


I've been an enthusiastic and loyal member since the late '80's, and have benefited much from belonging to the Society (as has my wife). When I returned to HealthInsight in 2010 for the REC effort, I made contact with a number of ASQ division leaders. Joe Fortuna responded enthusiastically, as I have noted before. He went so far as to invite me to participate in a Division Leadership conference in Milwaukee on ASQ-HCD's dime.

Other than Dr. Fortuna, my inquiries yielded only one other response -- from a Software Quality Division official, warning me that I might be using the ASQ logo without authorization.

Seriously, dude? Seriously?

I checked. I don't need "permission."

My whole point in seeking out Software Quality Division leaders was, well, you know, HIT. From the "About" page:
As stewards of the software quality profession, we are the global nexus for knowledge and recognized champion for excellence in software.

To provide members the benefit of collective learning, enabling them to be more effective practitioners of software quality and greater contributors to their employers, customers, and the profession.
The Champion for Excellence in Software. Except, it would seem, where HIT software is concerned. Search their site for "EHR," EMR," or "HIE."

That is pretty discouraging. 

I recall during the early-mid '90's, while serving as the Las Vegas ASQ Section Chair, that we had a "software life cycle quality" meeting presentation put on by a member whose job entailed fighter aircraft avionics software development at Nellis AFB. It was pretty impressive. I would like to think that HIT, within its own "space," is equally mission-critical and deserving of ASQ attention. Ya think?

"Logo use permission"? Seriously?

 Another cute little ASQ head-scratcher. I signed up to join a number of relevant LinkedIn groups a couple of months ago. The status of this one, below (yesterday):

Whatever. So, how're those Lean Enterprise Division quarterly meeting minutes notes coming along?

Carry on...

Maybe we'll get a SCOTUS ruling this week. Maybe not. If not this week, then inexorably next week. I thought it might be last  week. I was wrong.


No SCOTUS ruling today. In other NEW$...

Interesting. We'd applied for one of these CMMI grants. I had to write a section of the proposal, something about "patient self-management coaching" for three major chronic conditions (I had what we called the "clinic coaching" piece -- essentially "practice coaching"). I was dubious. We have some potential conflict of interest, quite frankly.

They awarded 107, out of what I heard was about 5,000 applications. It was a long shot out of the gate, nominally a ~2% probability of getting awarded, all else being equal (which it is most certainly not).

So they're expecting about a 111% 3-year ROI on these (~$.9 billion in grants). Right. Bend.That.Cost.Curve.

Push the money out the door ASAP. "Obligate" those funds against recission.


Still following this one (relative drops in the HH$ bucket, to be sure).
...The outcome of the [$793,456] evaluation will be a report including recommendations for enhancing and improving the Workflow toolkit. The report will provide results about the perceived usefulness of the Workflow toolkit. Results will be produced separately for practices and RECs as well as for both user groups as a whole. The report will also include specific suggestions on how to revise Workflow toolkit to make it more useful to its intended audiences.
AHRQ originally paid $494,028 for the "HIT Workflow Redesign Toolkit" (a rather pedestrian and dated compilation, IMO). Which, they now propose to consume an additional two years and $793k to "evaluate" (and, the evaluation of which looks troubling like it may perhaps involve some of the same entities contracted to produce it in the first place; still running that down).

I'll work for 10% of that, and you'll get a thorough and cogent report by the end of this year.

Seriously, people? This is John Stossel material.


I know the ObamaScare SCOTUS ruling has everyone on edge, but the Omnibus HIPAA HITECH Final Rule is under EO 12866 review at OMB. Their 90 day review period expires this Friday (June 22nd), but Dr. Mostashari recently said that the Final Rule will be released "by late summer." OMB can extend the review period one time for 30 days, but "[U]nder the Executive Order, the review period may be extended indefinitely by the head of the rulemaking agency."

Be nice if they issued it this Friday. It's under wraps until released, so we have no idea to what extent the Interim Rule Public Comment Period recommendations were incorporated.

Tick, tick, tick...


He's right. I read and wrote up his new book a little while back. It dovetails nicely in many respects with Dr. Toussaint's new book "Potent Medicine."

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