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Saturday, October 12, 2013

Cusp of Convergence?

The walled gardens are withering. The silos are splitting open. Disruptive technologies are shaking the heretofore sleepy status quo in myriad ways. No amount of Entrenchment Ambien will suffice to enable any return to the comfy seven figure healthcare space CEO Snooze.

The Disruption will be -- well -- disruptive. It will be messy. There will be casualties. Many of them richly deserving of their plight.

Things I just witnessed at Health 2.0 2013 in Santa Clara comprise yet another wake-up call for me. A lot to think about.

But first, apropos somewhat of my prior post, back to "disruption" of another sort.

Quixotic Queries Question Quality!
At, the plot thickens.

At, many people are still unable to create accounts, choose from a list of health care plans, and sign up for one. The system is down, or overloaded, or shows perplexing errors...

I was, it seems, a bit naive in thinking there were merely two cooks (or two bulb managers) in the kitchen behind The number of players is considerably larger than just front-end architects Development Seed and back-end developers CGI Federal, although the government is saying very little about who’s responsible. The Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS), which issued the contracts, is keeping mum, referring reporters to the labyrinthine for information about contractors. (I was not able to obtain any useful information from that site, though it does make look pretty good in comparison.)

By digging through GAO reports, however, I’ve picked out a handful of key players. One is Booz Allen, the people who brought you Edward Snowden. Despite getting $6 million for “Exchange IT integration support,” they now claim that they “did no IT work themselves.” Maybe Snowden can help us out on this one, though as far as I can tell, Booz Allen does seem to be ancillary to the overall project.

Then there’s CGI Federal, of course, who got the largest set of contracts, worth $88 million, for “FFE information technology and,” as well as doing nine state exchanges. Their spokesperson’s statement is a model of buck-passing: “We are spending 24 hours a day, seven days a week working with our client and working with our partners in order to stabilize the enrollment [process] and finish the roll-out of this very complex project.”

But which partners? The most interesting is Quality Software Solutions Inc. (QSSI). Despite the laughable name and inexplicable slogans such as “Quality is a Q word”—hard to argue with, I guess—they’ve been doing health care IT since 1997, and got $55 million for’s data hub in contracts finalized in January 2012. But then UnitedHealth Group purchased QSSI in September 2012, raising eyebrows about conflicts of interest.

In Congressional testimony on Sept. 10, QSSI vice president Michael Finkel said that there was no need to be worried about the conflict of interest—but he also revealed more about the architecture of and the data hub than anyone else has in the last week. Finkel described the data hub as the ultimate middleman of the entire system, “funneling” queries to databases from multiple sources. This would not be an impossible task, but it would require a formidable level of technical coordination. Imagine if Google, Apple, and Microsoft were suddenly asked to develop a website together...

Development Seed President Eric Gundersen oversaw the part of that did survive last week: the static front-end Web pages that had nothing to do with the hub. Development Seed was only able to do the work after being hired by contractor Aquilent, who navigated the bureaucracy of government procurement. “If I were to bid on the whole project,” Gundersen told me, “I would need more lawyers and more proposal writers than actual engineers to build the project. Why would I make a company like that?” These convolutions are exactly what prevented the brilliant techies of Obama’s re-election campaign from being involved with the development of To get the opportunity to work on arguably the most pivotal website launch in American history, a smart young programmer would have to work for a company mired in bureaucracy and procurement regulations, with a website that looks like it’s from 10 years ago. So much for the efficiency of privatization...


My friend Dr. Andy Pasternak sent me a copy of this to review (BMJ 2013;347 Sept 2013)

With the advent of pay for performance and quality standards, family doctors are now in the business of data reporting. We are paid to report “quality measures” and meet their targets. In the United States, where lawmakers, employers, and patients agree that the cost of healthcare is unsustainable, the government and industry are joining forces to enact structural and payment forms like meaningful use of electronic health records, pay for performance, and the patient centered medical home, which aims to transform the delivery of primary care. These programs reward healthcare providers with new computer systems and added management fees with the expectation of lower costs and measurable improvements in health. But this shift of our gaze to patients’ physiology and chemistry, and to our performance in managing it has unintended consequences.

Distracted by data
It is reported that physicians spend, on average, 11 minutes with their patients1 and listen to their chief complaint for only 22 seconds before taking control of the interview.2 During these brief encounters, to what or to whom do doctors attend? A structured history of the present illness taken by the medical assistant? The chronic disease flowsheets? A checklist of overdue prevention measures? Doctors have risen to their rank through a fierce competitiveness: we are experts at knowing what to know for the purposes of the test. Increasingly, we are graded on our performance on meeting national guidelines for the control of weight, blood pressure, smoking cessation, cholesterol levels, and diabetes, and the results are reported on consumer websites. It is possible, even likely, that such data will change our approach to patient care. They are already inexorably shaping to what and to whom we listen...

The widespread implementation of the electronic health record was intended to reduce the duplication of services, avoid prescribing errors, and increase physicians’ adherence to evidence based guidelines. But it also made it easier to “upcode” encounters with the click of a box. Physicians were often tempted, and sometimes encouraged, to check elements of the history and physical examination that were previously never performed. These failings are obvious when we read our colleagues’ office notes, and now patients aided by online portals are equally aware. The government and other insurers literally pay the price.
Added expense and privacy concerns may be the least of our worries. Computers are peerless at storing, sorting, and reporting data, the kind we gather from laboratory studies and vital signs and checklists. Healthcare payers and the insurance industry use these data to reward and thereby direct the delivery of healthcare according to what is most easily measured.

Even Luddites and sentimentalists must acknowledge that medicine cannot, should not, go back to the paper chart. Measurement is a good and necessary thing when it fosters socially responsible research and provides a reality check for human intuition, assumption, and self delusion. But it is never a neutral thing. What we measure unmistakably matters more than what we don’t. And in the age of pay for performance, it speaks to us in the form of incentives that cannot be ignored by our bosses.

Wider determinants of health
What is health? Or is that a fair question to ask experts on disease? Wendall Berry refers to health as membership. In other words, health is tied to our sense of connection to community. When disease disrupts the bonds of those connections, or requires that they be broken (as for the addict or victim of domestic violence), the doctor’s job is to ease and facilitate the patient’s transition. We are agents of change, from disease to health, from brokenness to a more connected, responsive, and responsible whole. Imagine for a moment that we could redesign our job and the dataset we utilize. What would it look like if there were no bean counters? Could we enlarge our job description to include serving as custodians for an oral history of wounded lives, or as chemists in the complex and volatile setting of human action and reaction?...

Facilitating change
A primary care physician’s day is largely spent managing the markers of disease: adjusting medications to lower blood pressure, body mass index, or cholesterol level. Too often, it seems like an exercise of “tinkering at the edges.” But once doctors find themselves powerlessness to “fix” the underlying problem, our role can shift to preparing patients for lasting change.

Over the past two decades, William Miller and Stephen Rollnick have revolutionized the way in which healthcare workers perceive their role in behavioral change. They call their approach “motivational interviewing” and see it as a directive, client centered counseling style that encourages patients to change their behavior by exploring and resolving ambivalence. Patients are not blind to the risks of their behavior or the benefits change. They simply find themselves stuck in habits both harmful and rewarding. Miller and Rollnick have identified four therapeutic behaviors that are consistently beneficial in helping patients make lasting change: the expression of empathy; the revelation of discrepancies between patients’ problem behaviors and their stated goals; the ability to roll with resistance to change; and, most importantly, support for self efficacy, when patients believe that change is both necessary and possible...

Designing our future
...It is not too late to retool the primary care workshop, to redesign the “product” that patients are clamoring for. Some experimentation has already begun. Practitioners of direct primary care have eliminated the health insurance middlemen by offering annual subscriptions. Patients receive affordable primary care; doctors receive an adequate income and sufficient time to spend with their patients. Eric Topol has pioneered the use of sophisticated diagnostic tools at the primary care bedside, thus eliminating the time and expense of a hospital referral. Dennis McCullough is an advocate for slower paced healthcare for elderly people, whose complex medical and social concerns simply need more time.

No doubt, biomarkers of disease will remain a central focus of the clinical gaze, but human faces are emerging on the periphery, and the voice of “America’s doctor” rings with a new air of authenticity: “I would take us all back a thousand years,” Dr Oz mused in a recent interview, “when our ancestors lived in small villages and there was always a healer in that village and his job wasn’t to give you heart surgery or medication but to help find a safe place for conversation.

In all fairness, Dr Oz may not be acquainted with primary care or its village healers. If he was, he might find a safe place for conversation and discover what we are learning about connection, childhood trauma, doctor-patient relationships, and the facilitation of change. If we are to remain the masters of our own creation the electronic health record and its data trove̶doctors must submerge it under our plane of awareness, hardwire it into our daily operations, and fence it from the sacred space we reserve for our patients. Only then can we do what we do best: sit presently with our patients and care for them. And allow them to learn, invest, and lead in their own recovery, and in the renewable health resource that is community.
My takeaway here is equal parts "God's Hotel" ("Slow Medicine") and Messrs Weeds' "Medicine in Denial," buttressed by other elements of converging technologies, e.g., evidence-based medicine flowing from increasingly transparent "big data," coupled with personalized data provided by self-monitoring apps and increasingly inexpensive "Lab On A Chip" devices such as those we have just seen demonstrated at Health 2.0.

But, where will government healthcare policy fit with all of this?
Can Government Play Moneyball?
How a new era of fiscal scarcity could make Washington work better

Based on our rough calculations, less than $1 out of every $100 of government spending is backed by even the most basic evidence that the money is being spent wisely. As former officials in the administrations of Barack Obama (Peter Orszag) and George W. Bush (John Bridgeland), we were flabbergasted by how blindly the federal government spends. In other types of American enterprise, spending decisions are usually quite sophisticated, and are rapidly becoming more so: baseball’s transformation into “moneyball” is one example. But the federal government—where spending decisions are largely based on good intentions, inertia, hunches, partisan politics, and personal relationships—has missed this wave.

Allow us to share some behind-the-scenes illustrations of what our crazy system of budgeting looks like—and to propose how the lessons of moneyball could make our government better.

When one of us (Peter) began his tenure as the director of the Congressional Budget Office in 2007, he took a Willie Sutton approach to the nation’s huge and growing fiscal mess: he went after health care, which makes up roughly a quarter of the federal government’s spending, because that’s where the money is.

The moneyball formula in baseball—replacing scouts’ traditional beliefs and biases about players with data-intensive studies of what skills actually contribute most to winning—is just as applicable to the battle against out-of-control health-care costs. According to the Institute of Medicine, more than half of treatments provided to patients lack clear evidence that they’re effective. If we could stop ineffective treatments, and swap out expensive treatments for ones that are less expensive but just as effective, we would achieve better outcomes for patients and save money.

Both parties should find much to like in such an approach. It would offer Republicans a way to constrain the growth of government spending and take pressure off private businesses weighed down with health expenses. And it would offer Democrats a means of preserving the integrity of Medicare and Medicaid and thereby restoring faith in a core government function.

And yet getting funding for the research needed to assess and compare medical treatments has been like pulling teeth. As a rule, legislators seem to lack a natural affinity for economists and budget analysts (alas, they are hardly alone). But Peter made himself exceptionally unpopular with some Democrats and many Republicans by insisting on such funding in the 2009 stimulus bill, and then working to expand it in the 2010 “Obamacare” legislation. Despite these modest successes, less than $1 out of every $1,000 that the government spends on health care this year will go toward evaluating whether the other $999-plus actually works.

Getting the right information is less than half the battle. Acting on it, once it’s in hand, is harder still. As one small example, some evidence suggests that moving toward “bundled” payments for all services needed by a patient during a course of medical treatment could produce better value than paying piecemeal for each service and procedure, because the piecemeal approach creates an incentive for more care rather than better care...
It is indisputable, however, that a move toward payments based on performance would harm some business interests. If most of your profits come from, say, a medical device or procedure that is covered by Medicare but doesn’t work all that well, you’re likely to resist anyone sorting through what works and what doesn’t, never mind changing payment accordingly. Health-care interests are wise to invest millions of dollars in campaign contributions and lobbying to protect billions of dollars in profits...
Interesting article. Another problem with "getting the right information" goes to the partisan politicization of quantitative findings. Even empirical conclusions of utter scientific rectitude get battered or summarily dismissed by those with powerful vested interests.

Fundamental to "Lean" process improvement (a.k.a. experimental scientific method 101) is the outset statement of the problem to be solved or condition to be improved, the methods to be employed, and the operational definition of what will constitute an interventional "success" or statistically "significant" improvement. See Dr. Toussaint's "On The Mend."

Outset. You don't decide arbitrarily after the fact on whether you're doing OK. This appears to be largely lost on government policy and program planners. Not to say that quantitative after-action review is of no value, but operational definitions of "success" are better baked in during the program planning phase.

More to come...

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