The KHIT Blog: Let a thousand banalities bloom

Sunday, January 18, 2015

Let a thousand banalities bloom

With respect to

"Leveraging Holistic, Transformational, Innovative, Disruptive, Patient-Centric and Empowering Digital Health Space Ecosystem Paradigm-Shifting Curations, including Seamless Agile Scrum Lean Six Sigma DMIAC Gemba Workflows and Big Omics Data Hadoop-coded Post-RDBMS, Post-SQL HL7® FHIR® API Synergistic Interoperability Solutions encompassing The Upstream, inclusive of All Stakeholders."

Crash Davis, - Bull Durham

I first came to health care ("healthcare"?) analytics in 1993 in the wake of years of writing 3GL/4GL "apps" code (pdf) in an environmental radioanalytics lab in Oak Ridge and then writing technical marketing literature (pdf) for an industrial diagnostics company in West Knoxville (I loved that gig, gave it up in deference to my sweetie).

After moving from Tennessee in 1992 in the wake of my wife's promotion and transfer to Las Vegas (Nevada Test Site radiation cleanup project QA Manager), I took up my first of three tenures with what was at the time known as the "Nevada Peer Review," a Medicare "PRO" (Peer Review Organization).

CMS, then known as "HCFA" -- the Health Care Financing Administration -- set about to "re-brand" the PROs into "QIOs" (Quality Improvement Organizations). We would henceforth progressively set out to "transform the healthcare system." No more stodgy post-hoc UTIL and "appropriateness of care" manual chart-abstration "QA" case reviews done by veteran, flinty-eyed, chain-smoking, shuffling floor-burnout-case RNs who could read adroitly across the dx and px codes and pt demographic data in the UB-82 output claims files (often with a cigarette in hand) and quickly paint you a vivid picture of the benes' clinical travails and their respective prognoses.

One of my first assignments (prior to our "QI Transformation") involved the empirical study of Medicare bene 5- and 30-day re-admissions in Nevada acute care facilities (pdf).

Another quick story from those days, as I originally posted on another of my blogs some years ago:

During my first tenure (early 1990's) serving as an analyst for the Nevada/Utah Medicare Peer Review Agency (they're now called "QIO's" - Quality Improvement Organizations), in addition to our core Medicare oversight work, we had a number of small sidebar contracts, one of which involved ongoing analytical assessments of the Clark County Nevada self-funded employee health plan. One morning I accompanied my Sup, our Senior Analyst Dr. Moore, to a regular meeting of the plan's Executive Committee, wherein we would report on our latest plan utilization/outcomes evaluation.

A portion of the morning -- perhaps a half-hour, IIRC -- was always devoted to hearing claims denials appeals brought by Clark County employees. This day, two appeals were heard: one regarding an outpatient medical claim, the other concerning a dental encounter. The total sum at issue was about $350. Both appeals were denied, thereby "saving" the plan this nominal amount.

Bored by this administrative tedium, as I sat at the conference table, I did a quick, rough estimate back-of-the-envelope calculation. About a dozen executive/professional people consumed a half hour adjudicating these disputes, or, equivalently, 6 FTE hours. Assume a plausible blended G&A-multiplied cost estimate of the total compensation time for all these folks, plus all of the clerical/administrative time consumed in the processing (and subsequently denying) of these minor claims from the moment of their filing to this very hour.

Clark County easily spent well in excess of an additional $1,000 to "save" $350 at the expense of these two hapless employees, by my reckoning.

Similar scenarios -- public and private -- surely play out every day within our "health care system." Clark County would have been way ahead to have simply vetted the initial claims for fraud and then paid them! (This is one observation implicitly at the heart of the "Universal Coverage / Single Payer" model.)

But, as my Senior Medical Director was fond of pointing out, "every misspent dollar in our health care system goes into someone's paycheck."

Fast forward 20-some years. I'm sure financially enervating claims processing hassles continue unabated, and CMS continues to "study" Readmits. Maybe this time we'll make significant "absolute rate reduction" headway on readmits. We have better data now.

Given that my wife and I were (and continue to be) huge Deming fans, I was ecstatic about the new QIO direction. We renamed ourselves "HealthInsight," and went all-in Kumbaya in an (only partially successful) effort to put our vestigial Utah/Nevada bi-state shotgun-marriage antipathies behind us (UPRO had acquired NPRO after the latter had lost its Medicare contract prior to my coming on board; the respective "cultures" could not have been more different -- straight-laced, Rated-G, cookies-and-milk LDS Utah vs neighboring Cutty, Camels, and Card-Counting Nevada).

We studied under the acclaimed Dr. Brent James at IHC to get up to speed on the latest in CQI Progressivism. I still have my 2" thick training manual. It's as relevant today as it was in 1994. Brent rocks.

Two subsequent episodic tenures with HealthInsight later (the latter concluding with my 2013 REC "retirement"), I'm still largely awaiting (yes, with some exceptions) all of these broadly systemic, paradigm-shifting transformations. Mostly what we see are hard-won incremental improvements, prevailing marginally over incumbent intransigence.

We do, however, seem to naturally excel at cherubic marketing cliches. I had my fill of them this week.

Oh, and, one I failed to mention: "The Uber of healthcare!"

Right. To go all hip-hop lyrical for a sec, healthcare needs an Uber like it needs another Gruber.

UPDATE

Couple of interesting comments over at THCB.

Indeed. I recall Dr. James cautioning us early on during our IHC training "don't think we're going to QI our way out of the larger societal problem."

UPDATE

Can Lean QI liberate health care systems from "the inefficient tyranny of annual budgeting"? From The Thedacare Center for Healthcare Value:

I've followed and repeatedly cited Dr. Toussaint's work across the life of this blog.
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More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
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"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
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"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
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"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
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"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
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"'Solutions' exist only in mathematics."

- Karen Martin
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"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
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"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Sunday, January 18, 2015

Let a thousand banalities bloom

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