Sunday, June 25, 2006

Baby Boomers and the Tipping Point in Healthcare

There They Go Again

It's easy to blame it on the Baby Boomers but a more accurate way to see it is to say there exists a critical mass of people entering the Healthcare System. This critical mass of people with healthcare needs is one of the major factors stressing the current traditional platform for delivering healthcare and transforming it into a new platform for delivering healthcare. The traditional platform for delivering healthcare has been through the Patient-Physician relationship. There was a time when this platform was a superb way to deliver essentially all healthcare services. In fact much of the success of the modern Healthcare System is due to the strength of this relationship and that is exactly why it is difficult to believe it could be replaced. I don't just think it could be replaced; I think it is being replaced. So what exactly do the Baby Boomers have to do with the Patient-Physician relationship and a tipping point in healthcare?

The Straw That Broke The Camel's Back

Baby Boomers are a large cohort of our population that is moving through our culture and influencing everything they contact. They are the people born between 1946 and 1964 and currently living in the United States. The first of them will turn 65 years old in five years and they are expected to double the size of this age group in the next 25 years. One of the great results of our Healthcare System is that people are living longer and healthier lives. While people may be living longer and healthier lives they still must live with many of the chronic health problems that have yet to be eliminated. Fifty years ago we did not have many treatments for these types of health problems but now we do and people expect to have access to the full range of healthcare services available to treat them. There is nothing magical about the age of 65 or being labeled a Baby Boomer. The simple observation remains: We have a large cohort of individuals entering an age when chronic health problems begin to occur at an accelerated rate. This, coupled with the size of this group, is one of the main factors creating a strain on the system. What we keep referring to as a "Healthcare Crisis" is really the outward manifestation of a system that is stressed and undergoing a transformation. As the first wave of Baby Boomers passed the age when health problems accelerate, the tipping point was reached, and the "Healthcare Crisis" officially began. But this wasn't the only factor.


As I mentioned before the fundamental platform for delivering healthcare information and services has been through the Patient-Physician relationship. The physician was the gatekeeper to the information and the provider of services. Twentieth century healthcare produced an enormous amount of information in addition to a wide range of services. The traditional platform has reached the point of diminishing returns on its ability to provide access to the supply of all the available information and services. It is not a matter of training more doctors. The problem is that doctors are human and humans have their limits. As the supply of information and services grew physicians needed to develop ways in which to manage this increasing supply. In the early part of the twentieth century this was accomplished by improving the training of physicians. As information and services continued to grow physicians began to specialize. Instead of mastering all that medicine offered we mastered smaller and smaller parts of it. While this allowed for the continued growth of information and services it also created an increasingly fragmented process for delivering healthcare. We can train more doctors but this will only create further specialization and fragmentation of the delivery platform. The delivery platform must be a common interface for the patient and be capable of coordinating the delivery of all available information and services. This can't be done with humans alone. With the accelerating demand this will require a new type of platform.


Not only is the traditional platform currently incapable of delivering all the information and services but the demand, in the form of a large cohort in need of those services, is growing beyond the capacity to deliver them as well. I don't think of this as the demise of the Patient-Physician relationship but I do see this as the demise of the physician as the central and only delivery vehicle of our Healthcare System. This is evident in the tremendous growth of non-traditional forms of healthcare delivery in the last few years. With each passing day the ranks of non-physician providers continues to swell. Patients will continue to seek out the services that only physicians can supply but it is very clear that they won't hesitate to obtain all other services from non-physicians if the price is more affordable and the service more convenient. This is also evident in the explosive growth of information on the internet. People will continue to seek out any and all sources of information and have no intention of limiting their access to healthcare information by waiting for a doctor's appointment. So what will the delivery platform for an emerging paradigm of our Healthcare System look like in the future?

And The Ability to Deliver

My best guess is it will be some form of information technology interface. It will need to have access to all of the best available and up to date information and range of services. It must be available at all times. What form this interface takes is anyone's guess but I suspect its earliest form already exists as simply as a computer connected to the internet. In time its capabilities will grow and it will take on new forms. It will coordinate each individuals care and provide what information and services it can provide. Those services that it can't perform will be done first by non-physician providers if they are capable of providing those services. When they are unable then it will be the physicians who provide the services. The gatekeeper will be the information technology interface whose information and limited services will also be available to providers to augment their ability to deliver what services they are trained to provide. Whatever form it takes it must also be very affordable. There are currently 3.3 workers for each social security beneficiary but in 2031 it is estimated there will only be 2.1. When we add in the existing and newly added Medicare benefits this will place an enormous tax burden on the workers in the United States. It is not a matter of saying the costs of our Healthcare System should come down, they must and will come down. It may seem like it's going to be Baby Boomer hell but I am more optimistic. We will find a solution. It may not look anything like the system the Boomers grew up with but if we are to continue to provide the needed information and services it is going to probably take on a completely different form from what we have now. Baby Boomers will continue to shape and influence the world they live in but as I said in yesterday's post it may "be in ways none of us ever imagined or possibly even intended."

Saturday, June 24, 2006

Resuscitation Centers: More Disruptive Innovation Theory for Hospitals

Just a Thought

Maybe what we need more of are "Resuscitation Centers" and not more "Centers of Excellence" focusing on the presumably narrowly defined needs of Trauma, Cardiac or Stroke patients. It is becoming more apparent that the sooner a life-threatening disease process is discovered and treatment initiated the better a patient does. This has been shown repeatedly in the treatment of trauma patients with severe injuries, cardiac patients with acute myocardial infarction, and in patients with an acute embolic stroke. Over the last several years it has also been shown that patients with severe sepsis also benefit from early goal directed therapy beginning in the emergency department and continuing on into the intensive care unit. The common theme for all these treatment plans is early identification of the disease process and aggressive evidence based interventions. The problem is that many of these treatment plans occur in multiple areas of the hospital and can involve multiple specialists.

Focused Care

Physicians tend to focus and segregate based on specialty. By doing so hospital administrators tend to narrow the focus of a hospital toward those specialties and create what are now known as "Centers of Excellence". This can be seen in the development of a controversial type of center known as "Specialty Hospitals". The advantage of these hospitals is that patients with a very specific disease process can seek treatment at facilities that specialize in the care of that type of disease. Many of these "Specialty Hospital" facilities primarily serve patients with insurance who need elective or semi-elective procedures. The patients with the more emergent needs who may or may not have insurance are often directed to tertiary care centers. Many of these tertiary care centers have continued to become more focused experts in the management of disease processes that present in an emergent fashion. They have also attracted individuals who specialize in the treatment of these types of diseases (trauma, heart attack, stroke). As these specialists came into contact with one another on a more frequent basis it became more important to coordinate care. This focused type of coordinated care led to the development of Trauma, Cardiac and Stroke Centers. It is these types of Centers of Excellence that have made it possible to improve the outcomes of patients with complex and life-threatening problems. So with all this high quality care why do we now need Resuscitative Centers?

It's Those Damn Baby Boomers

To put it simply, baby boomers are a large cohort of our population and they are getting older and living longer. Despite all the progress that has been made in healthcare over the last one hundred years, advanced age brings with it health problems and a critical mass of baby boomer health problems is beginning to come center-stage in our healthcare system. In my specialty of Trauma Surgery this continues to be a worse problem with each passing year. We're seeing an increasing amount of older trauma patients who have multiple health problems to manage in addition to their injuries. Because of the associated co-morbid conditions that tend to come with aging the mortality for those over the age of sixty-five is double that of a younger person with the same injuries. Years ago while I was a fellow in Trauma Surgery and Surgical Critical Care at Shock Trauma one of my colleagues suggested the day may come when we will need Geriatric Trauma Centers much like we have Pediatric Trauma Centers today. I think he was closer to the truth than many of us wished to believe.

The Need for a Hybrid System

There certainly is a growing need for the involvement of physicians more attuned to the special needs of the geriatric population who become victims of a traumatic incident. Trauma tends to be a disease process that is seen in a younger and healthier population. (It is the number one cause of death of those between the ages of one and forty-four.) As our population ages there comes with it the development of chronic health problems. It is these chronic health problems (coronary artery disease, asthma, diabetes, hypertension, etc.) which become complicating factors in the management of injured elderly patients. A hybrid system of care is evolving where specialists not used to being routinely involved in the care of trauma patients are more frequently called upon to take part. Many of these specialists (Cardiologists, Pulmonologists, Neurologists, Medical Intensivists) are crossing over from their own Centers of Excellence to join in the management of elderly trauma patients. In doing so we are evolving a new cluster of coordinated care.

Resuscitation Teams

They all have something in common. Within there own specialties they are experts in the ever developing field of resuscitation. Trauma Surgeons like to take credit for this field beginning with Dr. R Adams Cowley's famous claim of a "Golden Hour" in the early management of severely injured trauma patients. What this refers to is that severely injured trauma patients must be identified and aggressively treated as early as possible to improve their survival. This is demonstrating to be true for all emergent life-threatening problems. It may be that what we really need are "Resuscitation Centers" that have mastered the convergence of team members from the multiple "Centers of Excellence". Recently hospitals have been adopting the concept of "rapid response teams". These are small dedicated teams that can be called quickly to the bedside of a patient before they get into serious trouble. I think a more developed and highly skilled form of this will one day be present in all major hospitals. It will come in the form of a "resuscitation team" that will respond to all patients with an emergent life-threatening disease process anywhere in the hospital, including the emergency department.

Radical Sustaining Innovation

So why do I refer to disruptive innovation theory? In a previous blog I commented on the need for disruptive innovation at Trauma Centers for a different reason. In that post I discussed the observation that two-thirds of the trauma patients in the National Trauma DataBase have injuries that would be considered minor by conventional scoring systems. In addition, almost half of those patients were treated at Level 1 Trauma Centers which tend to be the most resource intensive hospitals in the country. I suggested this means we need a low-end disruptive innovation in the form of "Minor Trauma Centers" that utilize mid-level providers supported by algorithm based evaluation and treatment plans. In the words of Clayton M. Christensen, it would be a model that "targets overshot customers with a lower-cost business model". What I'm suggesting today is an idea that works at a more complex end of the spectrum. This fits the model of a radical sustaining innovation.

Convergence of Expertise

A sustaining innovation is an innovation that typically moves a company in an incremental fashion "along the dimensions that customers have historically valued". "Radical sustaining innovations are at the complex end of the continuum". According to Christensen, they "tend to be very complicated and expensive." They are opportunities that are available to companies that must "control large swaths of an industry's value chain". The advantage is that it provides companies the ability to "dramatically change their relative competitive positions in a market-place". The challenge is coordinating and integrating the multiple players involved in the various legacy systems represented by the "Centers of Excellence". The concept of resuscitation crosses multiple specialty service lines but appears to be emerging as a central theme in the management of acutely ill and injured patients with life-threatening diseases. A "Resuscitation Center" would have "Resuscitation Teams" that cross specialty service lines and focus on that period of time from the patient's arrival until that time when the life-threatening disease process is controlled. Specialists (Acute Care Surgeons, Intensivists, Cardiologists, Pulmonologists, Neurologists, etc.) could be team leaders or team members lending a specific level of expertise based on their training, experience and comfort level with the patient's specific problems. The radical difference is that a patient would no longer be seen by a group of independently functioning consultants focusing on a different physiological system but rather by a multi-specialty team focusing on the whole patient. This kind of team play may not be possible among baby boomers but may be necessary and inevitable among those who take care of us as we get older. It is becoming apparent to me that even as we baby boomers get older we continue to change the world in ways none of us ever imagined or possibly even intended.

Sunday, April 30, 2006

Surgeons, Simulators And SAGES

So Much To Learn With So Little Time

It is not just the amount of information in medicine that is expanding but also the usefulness of that information. In healthcare there is an exponential growth of information which is being used to create new treatments and operations all the time. It is one thing to keep pace with and manage the available information, but it is another thing to maintain and learn the skills required to perform the ever expanding array of new and innovative operative techniques. One way to do this is through the use of simulators. In a previous post I discussed the rational for using simulators to enhance training and reduce the potential for error. This last week I attended the SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) meeting in Dallas, Texas. While there I was reminded of the importance of simulators for the continuing education, training and development of operative skills throughout a surgeons career.

The Surgical Culture

There are barriers to the use of surgical simulators and the biggest one will arise directly from the current culture within surgery. Surgeons are very independent individuals. We don't like being told what to do and prefer giving orders as opposed to taking them. It's an extremely useful trait in the operating room and trauma room. These are environments that have little tolerance for indecision or time for debate. It often comes down to one vote and the one that counts is the surgeon in charge. Such skillful and autonomous individuals are more than likely going to provide some push-back when it comes to taking time off of their busy schedules to train on the simulator, but that is where the future of surgery is headed. Simulators will be used for basic training, research, maintenance of operative skills, acquisition of new skills and operative techniques, maintenance of board certification and hospital credentialing. Whether we like it or not surgeons are going to have to get on board with simulators. In time our culture will demand it and that will count as the one and only vote on whether we will do it or not.

Teaching Old Dogs New Tricks

When we complete our surgical residency it is assumed that we are proficient in all the skills that will be required of a surgeon throughout their career. In the early 1990's this paradigm was shattered by the introduction of an operation call laparoscopic cholecystectomy or the removal of a gallbladder using the assistance of a small operating scope and minimally invasive surgical techniques. What made this operation so radically different was the novel use of techniques not previously taught to most surgeons already in practice. Initially surgeons rejected the idea of using a laparoscope to remove a gallbladder, but in time the operation gained widespread acceptance. During this transitional period I was a surgical resident and witnessed first-hand the oftentimes awkward transformation of a surgeon use to open techniques learning the newer minimally invasive laparoscopic techniques. On many an occasion the surgical resident in training was more familiar with the laparoscopic techniques than the board certified surgeon who was supposed to be teaching them. Like I said it could be awkward. With the introduction of simulators we don't have to go through that experience ever again.

Pumping Up At The Simulator Lab

Simulators will allow us to not only develop new skills, but bring us up to date on skills we once acquired, but have allowed to atrophy from lack of use. Over time a surgeon tends to focus their career in a particular area of specialty. Some skills crossover from specialty to specialty, but some do not. Some skills never seem to be forgotten (like riding a bike) but other skills, usually more technical ones, degrade very quickly. When an old skill, which deteriorated due to lack of use, becomes uselful again, simulators will bring that skill up to an acceptable level of proficiency. Identifying the metrics needed to guarantee proficiency will take more work, but we are approximating that point. Many of the newer models of simulators (Simbionix, ProMis) have these types of metrics built into them. SAGES has also taken the lead in this endeavor with its Fundamentals of Laparoscopic Surgery educational module. The most encouraging thing I heard at the recent SAGES meeting was that everyone who is able and motivated can not only develop new skills and techniques, but can also improve an old skill that needs some tuning up. In time, simulators will become an enduring part of our surgical culture. It's time has come.

Wednesday, April 05, 2006

Simulation: Healthcare's Answer For A High-Risk Environment

To Err Is Human

Anything that has the potential to adversely affect the care delivered to patients is slowly being driven out of the Healthcare System and for good reason. In 1999 the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System, which stated that between 44,000 and 98,000 Americans die each year due to medical errors. Without significant changes in our Healthcare System this estimate is expected to increase. The quandary we face though is that innovation in Medicine is dependent on research, and research, particularly high-risk research, is dependent on trial and error. So how do we build a safer Health System and utilize the advances that can be gained by potentially risky research?

Primum Non Nocerum

Healthcare has embraced the philosophy of Total Quality Management (TQM). There isn't a hospital operating in the United States that doesn't have some type of quality improvement system in place. The medico-legal risk of not having one is too high. The advantage of embedding TQM philosophy in the Healthcare System strikes at the heart of the IOM's report. We need to build a safer system and in order to do that we must create a system that has an extremely low tolerance for error. In the process of doing this hospitals and the people who work in them must become risk adverse. Protecting the patient becomes paramount in such a Healthcare System and our highest value becomes patient safety. Research, particularly research involving patients, involves risk. So how do we in the Healthcare System engage in high risk activities in a risk adverse environment?

In Search Of "Best Practices"

One of the ways is to separate what we consider experimental from the standard of care. This is not always easy as part of what we sometimes refer to as the "art of medicine" is found in the gray, indeterminate area between the two. The resolution in today's Healthcare System is to decrease the heterogeneity of specific practice patterns by focusing on the delivery of "best practices". The advantage is to eliminate worst or even mediocre practices and raise the standard of overall care. Advances in the "best practices" standard will occur through a combination of "evidence based medicine" and "practice based evidence". Evidence based medicine uses research involving specific patient populations and consensus opinions among practitioners to derive "best practices". "Practice base evidence" uses statistical methods to evaluate existing patient care databases to derive "best practices" among practitioners providing care to a general patient population. "Practice based evidence" is a relatively low-risk way to identify "best practices". Research, on the other hand, is the gold standard for evidence based medicine but carries some increased risk. What we need is a way to further reduce risk in the research we perform as well as any other areas that are inherently risky but necessary.

Simulators Aren't Just For Pilots

Simulation is in its infancy but has enormous potential as one of many strategies evolving to reduce risk in our Healthcare System. The two main areas it will affect are research and education/training. Creating and testing research models on simulators prior to exposing patients to a research protocol will reduce some of the risk inherent and necessary in experiments. "Best practices" will follow a path that goes from hypothesis, to research simulation, to clinical research, to evidence based medicine, and on to the final testing ground as practice based evidence. In addition, future medical students and residents will train on simulators to learn and further develop their skills. This will reduce some of the risk that is inherent in medical education. The old saying, "See one, Do one, Teach one", will become, "See one, Sim one, Do one". The goals of simulation are to reduce error, maintain patient safety, encourage innovation and to constantly improve quality and outcomes in our health and our Healthcare System.

Wednesday, March 22, 2006

The Education & Healthcare Systems: Complimentary Means To An End

Approaching the Point of Diminishing Returns

The Patient-Physician relationship as the fundamental basis for healthcare delivery is approaching the limits of its capacity. The Physician as the gatekeeper and source of health information and services has functioned admirably in this role throughout the course of history. As the volume of information continues to rise and the demand for that information and associated services also rises the ability of any individual Physician to meet that demand decreases. The point of diminishing returns is quickly drawing near. There are short-term solutions, but ultimately a new, expanded platform for delivering healthcare will be required.

Managing Information

The short-term solution is to augment the capabilities of the Physician to manage the vast amount of information within our Healthcare System. Health Information Technology (HIT) is expected to facilitate this process at multiple levels. It can occur at the national level with the National Health Information Network (NHIN) or regional level with Regional Health Information Organizations (RHIO). Locally hospitals can do this with the development of Electronic Health Records (EHR) and Physicians can also participate with PDA's and software products such as Epocrates. While these measures will be helpful to assist in the management of information and coordination of care, other measures will be needed to improve the delivery of services and decrease the cost of care.

Managing Quality & Cost

Quality care initiatives are already being implemented that will standardize "best practices", utilize HIT, develop process and transform healthcare cultures in an effort to improve outcomes. New market approaches to improve the delivery of healthcare through concierge services, and Intensivist extenders or to reduce costs for evaluating and treating minor health problems over the phone, through the internet or while shopping at a local store. Despite all this we still need a long-term solution. The greatest number of healthcare problems and the greatest cost to our Healthcare System is the direct and indirect result of chronic disease and preventable injury and illness. This is where the lever of the new healthcare delivery platform should exert its greatest force.

Health Information As A Core Part Of The Educational System

Health information education needs to become as essential as reading, writing and arithmetic. It is ridiculous to think that a seven minute encounter with a Physician once or twice a year is enough time to impart the collected wisdom and knowledge of our Healthcare System, nor is it enough time for the average person to grasp that information and incorporate it into their life. Health information education needs to begin as early in life as possible. It's a whole lot easier to treat someone who has spent a lifetime developing healthy habits than it is to try and reverse fifty years of hard living. We've come a long way in public healthcare policy from promoting personal hygiene to improvements in public sanitation. I think the next step is to take our vast knowledge of health information and introduce it as a core educational goal.

The Education System As Part Of The Healthcare Delivery Platform

Health information education can be developed alongside our existing educational system. The two main benefits would be to provide an infusion of resources into our current educational system and to develop a culture of healthy lifestyle in our society that will reduce the effects and cost of chronic disease in the future. The education will need three main components. The first is the teaching of a fundamental core of health information. This occurs throughout the K-12 grades. The type of information taught depends on the educational level of the student. The second part is an information management core. Part of this will include health information but it will also be necessary for students to learn how to access, evaluate and apply all kinds of information to their life including health information. The third part is a controversy core. There will, no doubt, be controversy on what type of information is taught as well as how to manage it. While we may not agree on what is delivered in the first two parts we should agree that acknowledging and debating these controversies should be a part of the educational process. Whether we like it or not, debate can be healthy, and controversy is a part of the massive information stream with which we contend. Future generations should be prepared for both of these as much as managing the massive amount of new health information they can expect as they learn to manage their health. Education today is a more cost-effective solution for the health problems of the future.

Sunday, March 19, 2006

Attention Doctors:"Resistance Is Futile"

"You Will Be Assimilated"

This was the message of the cyborg collective known as The Borg in the television series Startrek: The Next Generation. It got me wondering if this is what the Healthcare System is really trying to say to Physicians? It also got me wondering if this is the message I'm sending in this blog at the expense of a more important message. I was reading one of Steve Beller's recent blogs on the importance of vision and found myself making the following comment:

"No individual, group, industry or nation is willing to undertake a journey if the destination appears no better than the point of origination."

This blog started as an attempt to better understand what is commonly referred to as our Healthcare Crisis. There are times when I appear to be leaving the impression that the future of Physicians is rather bleak. This is not my intention. I've come to realize that I must focus my attention on a vision of the future of healthcare that is not only more promising for our society but also attractive to Physicians.

Back To The Beginning

The position I've taken in this blog is that what we see as a Healthcare Crisis is a paradigm shift that is affecting the way healthcare is delivered. This crisis is best seen as the physical, psychological, social, economic, and cultural manifestations produced as we transition from an older, traditional model for delivering healthcare to an emerging, newer model for delivering healthcare. The platform for delivering healthcare in the traditional model was based primarily on the Patient-Physician relationship. The hypothesis discussed in this blog is that this fundamental relationship is being challenged and will be replaced. The new model will be based the Patient-Information Technology Interface. The Physician's primary role as a gatekeeper to the Healthcare System and its wealth of information and services is at the heart of what is being challenged. Nobody looks forward to losing their job and unfortunately this is a point I have emphasized to the detriment of the vision I see for Physicians in the future of the Healthcare System.

E Pluribus Unum

We tend to see the Healthcare System as a monolithic entity but it is really a complex-adaptive system. It is made up of multiple entities each of which is constantly adapting to the changes produced by their collective interactions. Physicians as a group are one of those entities but can be also by seen as individuals each with their own unique set of skills and talents. They will continue to adapt those skills and talents but will also need to have a vision of what role they will play in the future before they will consider relinquishing their role in the present. The growth of information available in our current Healthcare System has put Physicians at a disadvantage for being the gatekeeper and source of all that information. Having this wealth of information is one of the greatest strengths of our Healthcare System, but due to the volume of it, managing it is an impossible task for any one person. I think Physicians will continue to be a source of information and services but will be one of many sources.

There Has Got To Be A Better Way

As our Healthcare System increases in complexity, patients will depend more and more on Artificial Intelligence and Information Technology to act as both gatekeeper and a primary source of information and services. While this may appear threatening to Physicians I think it will ultimately be liberating. In the early days of medicine Interns were called upon to perform many of the relatively easy and mundane aspects of healthcare services such as drawing blood and transporting patients. This became known as SCUT (a.k.a. Some Clinically Useful Training). What a load of crap. It was cheap labor for the hospitals. As hospitals began to hire phlebotomists and transporters this freed up the Interns and Residents to focus on the more complex and important skills they needed to practice medicine. That is what I think Information Technology will do for future Physicians.

Seeing A Better Future Begins With A Better Vision Now

Too much of a Physicians time is spent doing related but not medically necessary work such as documentation, arguing with third party payers, and filling out an endless stream of various forms for insurance companies. Why we continue to fight to maintain this system is becoming the new eighth wonder of the world. Resistance may be futile but no one is expecting us to become cyborgs. We're not going to stop thinking because we have more Health Information Technology. We're going to become better at taking care of patients. They don't need the least of our skills and talent, they need the best of our skills and talents. The Healthcare System I want to be a part of in the future is one that both utilizes those skills and talents and values them. That is the vision we need to create because without it there will continue to be resistance.

Wednesday, March 15, 2006

Future Doctors and Past Legacy Systems

Choosing Among Medical School Applications: Easier Said Than Done

Doctors are the result of a finely tuned selection process. Students applying for medical school are chosen based on the type of Physicians we anticipate they will need to become. It doesn't say this anywhere on the application but it is implied nonetheless. We look at today's Healthcare System and choose students who will have the best fit for it. Traditionally this system uses a combination of GPA, MCAT scores, personal statement, interviews and completing the pre-requisites for medical school. This system has worked well for the traditional, established model for delivering healthcare but what will happen if our healthcare crisis is really the sign of an emerging, new model for delivering healthcare? Are Physicians already trained in a traditional model of healthcare as capable of selecting future Physicians who will practice in an environment where an emerging, new model of healthcare is evolving?

Legacy Systems

The traditional model of healthcare is, in my view, a legacy system. The expression "legacy system" has been used in the computer industry and has been defined by some as "any information system that resists change." Others have described it as "inflexible", "difficult to integrate" and costly to maintain. In a recent description in Wikipedia the characteristics of a legacy system consist of the following:

1) "Large, monolithic, complex"
2) "Requires close to 100% availability"
3) "The way the system works is not understood"
4) "The user expects that the system can easily be replaced when this becomes necessary."
5) "The owner sees no reason for changing it."

With the exception of this last characteristic, it appears that, by all accounts, referring to the traditional model of healthcare as a legacy system is on target. Legacy systems don't show up overnight. They develop and mature over a relatively long period of time. They become very good at producing a product or delivering a service, but as they mature they reach a point of diminishing returns. This is what makes them vulnerable to disruptive innovation.

Sustainers Aren't Disrupters & Disrupters Are Sustainers

In Clayton Christensen's recent book Seeing What's Next he discusses innovation in the context of healthcare and states, "Improving the lives of people suffering from debilitating diseases is certainly a good thing. But it will not transform the healthcare industry into one characterized by affordability, convenience, and effectiveness. These things come through disruption." One of the things that makes legacy systems good at what they do is sustaining innovation, particularly the kind that sustains the legacy system. How they do that is to recruit people who are very good at sustaining innovation. People who are very good at sustaining innovation and who blend well with legacy systems tend to not be very good at disruptive innovation. They weren't recruited for their disruptive innovation skills, they were recruited for their sustaining innovation skills. So what does this mean for the future of healthcare?

Resistance to Disruptive Innovation

If our current model for delivering healthcare is a legacy system then the people who make up its core of human resources are committed to sustaining that system. These same people are also charged with recruiting the future human resources. This means our future Doctors. Based on this I predict that any innovation that is disruptive in nature is more likely to come from outside the traditional resources. Any disruptive innovation that improves "affordability, convenience, and effectiveness" risks resistance from those within the legacy system (like Physicians) particularly if it directly challenges their role in that system.

A New Type of Doctor for a New Type of Healthcare System

Future Doctors will need to be more flexible and willing to integrate into a rapidly changing Healthcare System. The old criteria may no longer be enough or even considered for future candidates applying to medical school. If we are really moving toward a new platform for delivering healthcare as I have proposed in this blog than the criteria for selection may need a disruptive innovation of its own. Pre-Med students may need to prove their "competitiveness" by demonstrating their ability to integrate as a team member in a complex-adaptive system. Either way future Doctors will, most likely, not be playing by the rules of the current system but a system that is still in its evolution. My advice to all medical school admission committees. As always, choose wisely and look to the future, because who you choose will be building the next legacy system.

Saturday, March 11, 2006

Bandwidth, Service Lines & Healthcare Tiers

Lions, and Tigers and Bears, Oh My!

Since I am a relative new-comer to the world of blogs, playing catch-up is a constant exercise. Lately I've been reading more and more on the concept of bandwidth and the need for multiple tiers of service. My healthcare-system-centric view of the world forces me to consider how this may be affecting the concept I've focused on in this blog. Which is: What we are experiencing as a Healthcare Crisis is really the transformation of our Healthcare System from an older, more established paradigm to an emerging, new paradigm for delivering healthcare. So what got me interested in bandwidth?

Maverick Ideas

There is a very good chance that the only reason you are reading this blog is because you stumbled across it on your way to something else. Be honest, you know it's true. I tend to find a lot of interesting things that way on the internet. I ran across a blog Mark Cuban wrote on the subject of bandwidth and immediately started wondering how this could affect the future of Healthcare. His discussion focused on "multiple tiers of service" and the development of "HOV lanes" or "toll roads" within the bandwidth to access these services. The idea is that there needs to be "mission critical reliability" for "mission critical applications". In a recent blog of his I commented that this may mean the bandwidth equivalent of "911 lanes" for "medical service lines". I'll leave the discussion and debate of creating tiers for bandwidth traffic to the more informed minds, but I couldn't help but wonder what role this may play in an emerging, new paradigm for delivering healthcare.

Out With The Old And In With The New

There is a steady drumbeat of support in this country for the idea that our Healthcare System is in ruins and is crumbling before our eyes. I have a different opinion. What is crumbling before our eyes is the old paradigm. At its foundation is the patient-physician relationship. Physicians have been the gatekeepers to the information and services this great system can provide. What if the nature of that traditional, established role was being challenged? I believe that is what is happening and it makes for some unsettling times. Some might call it a crisis. Changing a model for delivering healthcare is not going to be an easy or very comfortable experience for those of us in the trenches. Access to healthcare information and services are already beginning to become available through alternative venues. I think this is just the beginning of the challenge to the old paradigm.

It's Only the Beginning

Nurse Practitioners and Physician Assistants are beginning to independently provide basic Primary Care health services through outlets such as MinuteClinic, and Medspot. More are sure to come. To further improve access to healthcare services patients can now get advice over the phone via Dial-a-Doc or place an order over the internet for their pharmaceutical needs via Kwik-Med. This is to say nothing about the vast archives of information on medical research available on the world wide web. Despite growth in the cost of healthcare I think these are subtle but very real trends for the future of healthcare. All seek to improve access, decrease costs and provide services for, what Clayton Christensen refers to as, "overshot customers" using "disruptive innovation".

The Anywhere-Anytime Healthcare System

The convergence of easy access to: low cost providers, service selection and real-time availability to health information technology points to the internet. It is becoming apparent that not all healthcare needs require an appointment in a Physician's office or even a Physician. I've discussed this in a previous blog. What if we could not only access a "Provider" anywhere-anytime but also have that visit immediately recorded in our healthcare record? I'm not talking about a real walk-in clinic, but a virtual walk-in clinic. It would be open 24/7 and available wherever and whenever you can access the internet. Medical service lines would be offered much like cable TV channels or pay-for-view programming. If you have a relatively minor, but urgent healthcare need you can access a virtual provider via the internet. The Healthcare Tier you subscribe to will determine the level of interactivity you will have with your virtual reality provider. Customized packages can also be included to further enhance the experience. All information on the virtual visit would be stored in a personal health information record via the National Health Information Network.

Do We Need Emergency Lanes for the National Health Information Network?

With the anticipated growth of bandwidth use, the question remains: Will there be a need for "911" or emergency lanes within the bandwidth for those with pressing healthcare needs and is this going to be a "mission critical application"? My guess is that if it reduces the number of those with non-urgent/non-emergent needs in the Emergency Department and Physician's office waiting rooms then it will be worth the investment. The key is to not only provide access to the service but deliver it at a markedly reduced cost. The other potential bonus is that with improved access and low cost people will seek advice earlier in the course of a disease and, with any hope, avoid the catastrophic effects of late intervention. Virtual Providers could not only treat minor health problems but also get patients into see Physicians earlier in the course of a disease where they can be maximally effective. Now that is what I call mission critical.

Sunday, March 05, 2006

Uncharted Territory and the Healthcare Crisis

Crisis, What's a Crisis?

Why is it important to understand that the changes we are experiencing in Healthcare are appropriately described as a crisis? First we must understand what a crisis is. When we use that term to describe an experience most people think of the the experience expressed as a traumatic event. It conjures up images of fear and confusion. While this can accompany any crisis the primary meaning of the term is "a critical or decisive moment". If we are experiencing a Healthcare Crisis we must see beyond the fear and confusion and act decisively during that critical moment. I would argue that it is not just one critical moment or decision but a series of them which we must engage. This will take some planning.

Kind Of Like Being a Teenager But Not.

The position I have taken on this blog is that what we are experiencing as a Healthcare Crisis is a transformation process. We are undergoing a paradigm shift in healthcare delivery. In this process we are transforming from an older, established model for delivering healthcare into an emerging, new model for delivering healthcare. In a previous post I compared it to another period of potential "crisis" in human development. That is the transition from childhood to adulthood that we call puberty and adolescence. The whole period of time can be seen as a "crisis" for the individual experiencing the transition but is in fact a series of developmental steps that are essential for human growth and maturity. What distinguishes this type of development from that seen in Healthcare is that the stages of development are anticipated and predictable. As an individual develops they can encounter problems, and while those problems may be unique to that individual, they are not necessarily considered unique to those who have already matured into adults. For the most part this developmental step is charted territory and there are plenty of experienced travelers available to guide the way. This is not necessarily so in the development of a complex adaptive system such as Healthcare.

Who Will Show The Way?

What we are missing in this current Healthcare Crisis is a map. A plan for getting us from where we are, to where we wish to be. While we lack such a map we do not lack those who think they know the way. The reactions to the crisis fall into two camps both of whom claim to have the solution. There are those who see the crisis as one problem which requires only one solution, and those that see it as many problems requiring multiple solutions. The extremes of these two are the "Single Payer, We Need a Socialized Healthcare System" camp and the "Free Market Capitalists, Let the Market Solve It" camp. They each claim to own a map that will guide us along a path that neither of them has traveled, to a place neither of them has seen. That approach may work well in a simple system moving from point A to point B, but is not particularly suited for a complex adaptive system. Kevin Dooley says in a complex adaptive system the order is "emergent as opposed to predetermined". In addition a complex adaptive system's "history is irreversible" and its "future is often unpredictable". Deciding which way to go will not be as simple or predictable as we would like to believe it is.

Where's Christopher Columbus When You Need Him?

If this is uncharted territory there is no map. So how do people travel in uncharted territory? Well there was a time when it was not uncommon to travel without a map. People didn't always arrive at the destination they anticipated but could discover something greater along the journey. Columbus sailing to the Indies and discovering the new world comes to mind. He created the map along the way using dead reckoning as his navigation tool of choice. If we have no idea what this emerging, new model for delivering healthcare is going to look like what makes us so confident we know the path that will lead us to it? I think we need a form of dead reckoning to make our way through this territory. The goal is to create a map that will lead us to a model for delivering healthcare that is far superior to the one we currently have. If this is truly a paradigm shift then that model and the path to it will look much different from the ones we have. The question is how do we create a map of this uncharted territory?

Map Making 101 for Complex Adaptive Systems

Such a map will need to employ certain features in its creation. It will need to be built bit by bit with each new change submitting to a form of natural selection. In a complex adaptive system the basic building blocks are agents which "seek to maximize some measure of goodness or fitness by evolving over time". The plan can be expected to undergo three types of change according to Kevin Dooley. "First order change, where action is taken in order to adapt the observation to the existing schema; second order change, where there is purposeful change in the schema in order to better fit observations; and third order change, where a schema survives or dies because of Darwinian survival or death of its corresponding complex adaptive system." Our attempts to fit the observations of the Healthcare Crisis into existing constructs such as "Socialized Medicine" and "Free Market Economics" may be first order changes and inadequate to deliver a sustainable long-term solution. Some other type of construct or schema may be necessary for a second order change to better fit the observations of the crisis at hand.

The Best Map Is The One That Works

From the outset we must acknowledge that it is a journey through uncharted territory. We must recognize that the journey may take longer than anticipated but will ultimately have a beginning, a middle, and an end. There are a lot of educated guesses about which direction we should take and what we will encounter along the way but nobody knows for sure. We must be very clear on what our objectives are along the way and employ a feedback system to guide course corrections as needed. Each phase of the journey will have its own set of problems that must be resolved before the journey can proceed any further. These problems must be prioritized as to their immediate importance to the journey. Some of these problems will be predictable and can be prepared for in advance. Others will need to be resolved as they are encountered. We must think of this journey as an essential step in our development as humans. We must never forget the final goal is to improve the health of ourselves, our society and our planet. We must be willing to seize the moment and make the crucial decisions before us. If that means we must improve our understanding of complex adaptive systems than that is where we begin the journey. As Francis Bacon once said, "Nature to be commanded, must be obeyed."

Thursday, March 02, 2006

The Healthcare Crisis: Adolescence Revisited

If I Only Knew Then What I Know Now

The most important and enduring lessons learned along the way in life are usually the most personal. In my recent journeys I discovered this simple truth once again. I write in a journal almost every day and have done so for years. Toward the end of last year I noticed a disturbing trend in my daily observations. They tended to revolve around the issue of the healthcare crisis in the United States and my increasingly negative opinions of it. There was no shortage of disparaging remarks and they covered the gamut. The list included: medical liability, health insurance companies and their CEO's, trial lawyers, hospitals, government officials and of course my fellow colleagues. I had enough and I quit. I closed my practice and went on a sabbatical. It was one I believed would be a permanent one from the healthcare industry. One day something happened and that all changed.

I Would Ask Different Questions

It was a typical day. I woke up, made some coffee and sat down to write in my journal. It was now just over three months since I last worked in healthcare. I was about to begin another journal entry in what would have been another rant on the despicable state of our Healthcare System. As I picked up the pen a question crossed my mind. What if I'm wrong? What if all my negative musings were the result of how I framed questions and not an accurate reflection of what was really happening in healthcare. There is an amazing property of the mind. When asked a question, it seeks an answer. (News reporters learn this early in their career and use it to their advantage when investigating a story.) Often-times the answer the mind seeks comes back in a form that mirrors the emotional and intellectual state from which it was generated. If you ask what is wrong with this god-for-saken Healthcare System the mind will seek problems that support that view of the system. As it turned out it was not a typical day. I started asking different questions and started getting different answers. It wasn't until I completely separated from the actual practice of medicine that I could begin to view it from a completely different perspective and ask different questions.

Seek Different Answers

That one simple question made all the difference. It led to a different way to not only view healthcare but also became a tool to ask questions that led to a deeper understanding of the Healthcare System. What if what we experience as a healthcare crisis is really a transition point in the growth or evolution of healthcare? That would mean we are transforming from a system we have known all our lives into one with which we have no previous experience. The process seems frightening and conjures up images of a crisis on a daily, if not constant, basis. For some it may seem like puberty and adolescence revisited. That period of time when we undergo the physical, psychological and social changes that takes us from childhood to adulthood. No one would doubt the importance of such an important period of time in human development or the necessity of the changes that must occur, but just try to point that out to an adolescent. Their daily lives are filled with more important concerns like: acne, dating, popularity, peer pressure, good grades, getting a driver's license and appearing independent, especially from their parents. They really don't have the time, inclination and in some cases the emotional and intellectual capacity to "get the big picture". It isn't until we emerge out of adolescence that we can take in that view. Even then we move on to the next phase of development and leave behind such valuable insights.

And Live a Fuller Life

So back to my original question, "What if I got it wrong?" What if the healthcare crisis is a transformative process? What if all of the problems we accumulatively interpret as a crisis are really the necessary and oftentimes painful steps required for our Healthcare System to transform from what it is to what it can become. It doesn't mean that the problems we experience on a daily basis are not real problems. They are. It is understanding their role in that process. Healthcare has undergone many transitions. There once was a time when we had no antibiotics to fight infection, chemotherapy to fight cancer and surgery to treat operable pathologies. Sewage disposal, water treatment and public health policy were non-existent for most of human history and yet we eventually began to incorporate these great advancements into our system. I think the time has come again. It is a necessary and yes even painful process at times, but it will ultimately strengthen our Healthcare System and our society as well as prepare us as a people for the next phase in life.

Monday, February 27, 2006

The Paradox of Success and the Healthcare Industry

The Cycle of Renewal

It may not look like it but many of the woes we see as a looming crisis in our Healthcare System are the result of our successes, not our failures. During my sabbatical I had the opportunity to reflect on my personal life as well as professional career. Recently I read John R. O'Neil's book, The Paradox of Success, and could not help but notice the parallels between what I experienced personally and what I observed to be happening in healthcare. O'Neil refers to it as the "Cycle of Renewal" and notes it is as important for individuals as it is for organizations. I think it applies to systems as well and what all the signs of the crisis are saying is it's time for renewal.

Surfing the S-Curve

The Paradox of Success utilizes an S-curve to describe the major stages one goes throughout the cycle. The bottom of the curve is the initial phase where the greatest amount of chaos exists. Learning is slow and frustrating. As one ascends the curve competence improves markedly and confidence builds. Performance continues to improve in a non-linear fashion until it reaches the top of the curve as one approaches the peak of success. Along the top of the curve the slope levels off and the pace of learning slows. We reach the point of diminishing returns and the slope begins to descend. We appear to be at the summit of our success but are beginning to stagnate. We've become so use to the non-linear growth phase we assume it will continue forever but as the cycle predicts it doesn't. It's a dangerous time. Doubt replaces confidence and slowly the crisis begins to build. Our first impulse is to fight this feeling. It can't be happening, we assure ourselves, but it is. We want to return to the glory days when we were on the rise up to the peak and each day brought new and exciting challenges. In our panic we can continue our futile struggle or choose to undergo renewal. Renewal is where hope lives. O'Neil draws the analogy of the surfer "who senses the dynamic wave beneath him, and... knows it is time to abandon the sinking or breaking wave and catch a new one that is building."

"You cannot solve the problems of the present with the solutions that produced them."
Albert Einstein (1879-1955)

In Geoffrey A. Moore's book, Dealing with Darwin, he also describes a similar cycle that he refers to as a "category-maturity cycle". A technology, service or industry will inevitably pass through this cycle and face the challenges each category provides. This cycle also has an early phase followed by a growth phase. The growth phase is a time when each day brings new and exciting challenges. Growth is non-linear and it is assumed it will continue forever. In time, a mature phase sets in when the disruptive innovation that initially precipitated the growth phase becomes entrenched. As it develops it soon becomes a legacy system which becomes large and less maneuverable. Much like the Titanic, the impending collision with the iceberg is inevitable but the great ship cannot turn in time to avoid a crisis. The crisis for mature phase industries is the approaching declining market. Depending on the solution they innovate they can either extend the shelf life of the current innovation or create a disruptive innovation and enter a new market. It is the new and typically disruptive innovation that helps solve the problems created by the old innovation.

"The Times They are a Changin."
Bob Dylan

Healthcare is made up of many people and industries each of whom will achieve some measure of success. The paradox is that as we achieve this success and rideout its natural cycle there is a tendency to view both ourselves and the industries we support as somehow failing after we reach the summit. The point of diminishing returns and the crisis it can invoke is not a sign of failure but a sign of past success receding and the need to prepare for a new cycle. I think our crisis in Healthcare is such a sign. It is going through a transformation from what it was to what it will become. Both of the above authors advocate for greater awareness and preparing for the next cycle or phase. Whether it is the "renewal imperative" or "repurposing resources for core" the encouraging news is that this crisis too shall pass.

Thursday, February 23, 2006

Trauma Centers and the Need for Disruptive Innovation

Seeing What's Next

Recently I read Clayton M. Christensen's new book, "Seeing What's Next: Using the Theories of Innovation to Predict Industry Change", and found myself feeling more invigorated at the thought of participating in the transformation of our Healthcare System. The position I have taken in this blog is that what we are experiencing as a Healthcare crisis is really the transformation of an established paradigm for delivering healthcare into a new emerging paradigm for delivering healthcare. Chapter eight of "Seeing What's Next", titled "Healing the 800-Pound Gorilla: The Future of Healthcare", indirectly suggests this hypothesis and specifically outlines how it not only can happen but in all probability is happening. Christensen's "disruptive innovation theory" demonstrates how "new organizations can use relatively simple, convenient, low-cost innovations to create growth and triumph over powerful incumbents." The underlying assumption is that healthcare is an industry and like all industries is subject to the forces that influence the market in which it thrives. If so, then how could it influence the field within which I trained, Trauma and Surgical Critical Care?

Is the Field of Trauma Really in the Gunsights of Disruptive Innovation ?

Trauma is a field that is ripe for innovation based on one simple observation. A large proportion of the patient population served is what Christensen would describe as "overshot customers". This is a patient population (particular customer segment) for which existing services are "more than good enough". You may ask, How can I make this claim? I base it off the observation that the majority of patients treated at Trauma Centers and registered in the National Trauma Database (NTDB) have minor injuries. Over two-thirds (68.4%) of the patients in the NTDB were found to have an injury severity score consistent with a minor injury and yet all of them were evaluated by a Trauma Center. Nearly half (49.1%) of all patients with minor injury severity scores were treated at Level I Trauma Centers which are the most resource intensive hospitals in the country. So why do almost half of the least injured patients in the United States end up at centers which are the most expensive providers of healthcare services? Like many things in life, it's complicated.

Is it Possible to be Too Good?

Trauma Centers, especially Level 1 Trauma Centers are victims of their own success. To maintain a "Level 1" status a trauma center must commit to a very high level of resources, not the least of which is human resources. Patients who meet specific anatomic (gun-shot wound to the chest), physiologic (low blood pressure from blood loss) or mechanistic (rollover motor-vehicle accident) will be triaged to a trauma center. Trauma centers have the resources and expertise needed to treat the most severely injured patients on a 24/7 basis. As they became proficient at what they did they attracted more patients. Trauma patients usually don't choose where they go so this is done by the EMT's or Paramedics transporting the patient. Since they prefer not to undertriage (send a patient with a serious injury to a non-trauma center) they tend to overtriage (send a patient with minor injury to a Level 1 Trauma Center). The Trauma Centers are loathe to discourage business so the cycle continues to progress and the total trauma patient population is "overshot". In most Trauma Centers Trauma Surgeons are the leaders of the teams activated to evaluate these patients. What this means is that a Surgeon who spends most of their professional career mastering the art of Surgery ends up taking care of patients who don't need a Surgeon to care for them. How does this happen? I've commented on this in a previous post but it is worth repeating.

"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)

There is actually another reason and in the parlance of the business world, the Trauma Centers have become the "incumbents" of the trauma market. There once was a day not so long ago when the high end care provided by modern day Trauma Centers was not available. It took the vision, dedication, hard work and commitment of individuals such as Dr. R Adams Cowley to introduce the "disruptive innovation" of Trauma Centers and move it into the mainstream. Trauma Centers have gone from being rare and the exception to the common and the exceptional. As with all growth industries Trauma Centers have matured and in doing so have "overshot" their customers. While this may introduce an element of waste it also exposes the industry to opportunity for innovation. Overshot customers create potential opportunities for "Low-end disruptive innovation". This is an "innovation that offers overshot customers good-enough performance along traditional metrics at lower prices".

Innovation Lessons from Healthcare

In "Seeing What's Next", Christensen et al, point out there are three general lessons to be learned regarding innovation in healthcare which are:
"1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Nonmarket forces affect the market for innovation by influencing industry players motivation and ability."
So how does this apply to the overshot customers within a trauma patient population?

"Bad laws are the worst form of tyranny."
Edmund Burke (1729-1797)

Trauma Centers are very good at categorizing patients and providing timely treatment. Most of the rules, that is protocols, for guiding treatment have focused on the more severely injured patients as their injuries are the most life-threatening. Minor injuries were relatively easy to treat and did not warrant the time and energy to develop specific rules for treatment. This is particularly true at the major Trauma Centers. Protocols were reserved for the common injury and disease patterns seen in the more severely injured patients. That is, after all, the specific patient population for which Trauma Centers were designed. Based on disruptive innovation theory I predict that the development of protocols that specifically address the needs of those patients who have minor injuries and are being treated at Trauma Centers will be one of the first steps in the direction of a low-end disruptive innovation in the field of trauma. The key to these protocols will be to incorporate them into a quality improvement program that is designed to continually improve the care of the patients for whom they were developed, because without this they are no better than "bad laws".

Now the Difficult Part to Accept

With a set of rules to guide medical decison making in the treatment of patients with minor injuries this allows the next step to occur. This is a "provider-level disruption" where less-skilled providers such as Nurse Practitioners (NP's) or Physician Assistants (PA's) provide care which does not require the judgment and skill of higher-skilled providers such as Trauma Surgeons or Emergency Medicine Physicians. This also allows the movement of treatment to areas that are more convenient and less costly for the patient. Free-standing "Minor Trauma Centers" are unlikely due to the restrictions on specialty hospitals and the fact that they would share the same "value network". A more likely scenario is for the "Incumbent" Trauma Centers to internally develop "Minor Trauma Center" sub-specialty areas on the same physical site as the major Trauma Center. While this is already happening to some degree at very busy trauma centers out of necessity it is not the norm at most centers. So if two-thirds of a Trauma Surgeons patients are being evaluated downstream by NP's and PA's then what is the Trauma Surgeon going to do?

Move upstream

The Trauma Surgeon will do what any service provider does in a mature market. They will need to go upstream. Most facilities already utilize the Trauma Surgeons skills to cover Urgent and Emergent General Surgery so this is not a new market. There has been a great deal of discussion among Trauma Surgeons and the current view is that they should become Acute Care Surgeons. In case anyone in the medical community hasn't noticed we already are Acute Care Surgeons. I think we need a more radical "sustaining innovation". Moving upstream means acquiring new skills to meet the demands of the market in which they most commonly practice. If Trauma Centers in the United States continue to see shortages of Neurosurgeons, Orthopedic Surgeons and Plastic Surgeons then it is up to the Trauma Surgeons to develop the skill sets and the training programs necessary to provide those services. As those specialties move further upstream to ambulatory surgical centers, specialty hospitals and non-trauma centers they will leave behind them a void in the availability of essential services. As NP's and PA's move in from below and surgical specialists exit from above there will come a time when the Trauma Surgeon will need to step up and move as well. If we are going to do it then I suggest it is better to lead than follow. I don't think Dr. Cowley would mind.

Saturday, February 18, 2006

Evolution, Natural Selection, and Our Healthcare System

Healthcare Through the Eyes of Darwin

In Geoffrey A. Moore's recent book, "Dealing with Darwin: How Great Companies Innovate at Every Phase of Their Evolution", he examines a company's or industry's ability to adapt to challenges in the marketplace as a Darwinian exercise in natural selection. As I read this book I couldn't help but ask, "Do the changes we see in our Healthcare System fit into to this type of model?" and "If our Healthcare System is evolving, where does it currently stand?"It is probably just as important to ask, "And what is it evolving into?" Moore contends that innovation is what drives an industry's evolution. He writes, "If you are going to be successful with innovation, you have to understand that different categories (along the life-cycle) reward different types of innovation at different points in time." Those "categories have a beginning, a middle, and an end." Much of his book focuses on technological innovations but he is quick to point out it can also refer to a business model innovation. This is what got me interested because I think we are experiencing a series of innovations that will continue to fundamentally change the face of healthcare.

The Life-Cycle of Innovation

Moore breaks down the category-maturity life cycle of a technological or business model innovation into five categories. They are in order of their appearance in the life cycle: The Technology Adoption or beginning of the innovation followed by The Growth Market, The Mature Market, The Declining Market and The End of Life Market. So how and where does our Healthcare System fit in? I think it begins at the cornerstone of the system. If we think of the Patient-Physician relationship as the core of the established paradigm for delivering healthcare, then the real question is, "Where does this "business model" fit in the category-maturity life cycle?" Some may argue it is in the early phases of the Declining Market but I think it is more likely in the late phase of a Mature Market. As I have suggested in previous posts I believe what we are witnessing is the emergence of a new paradigm for delivering healthcare that is displacing the established paradigm. In accordance with this is the idea that the traditional core of the established paradigm, that is the Patient-Physician relationship will undergo a radical change. If so, then what evidence exists today to suggest this may be happening?

Business Structure

In order to approach this question we first have to understand the type of business architecture we are evaluating. Moore breaks this out in to two major types: The complex-systems architecture and the volume-operations architecture. By definition healthcare tends to be a volume-operations model which are more consumer oriented businesses. The goal is to "generate both volume and a variety of offers" or in this case services. They are "optimized to meet the three basic values of retail markets: price, availability, and selection." Translating that into healthcare that means low cost, easy access, and choice of services that meet the standard of care. Innovative solutions will not only need to address each of these values but do it in a way that fits with the life-cycle category of a maturing market.

Late Phase, Mature Market

In order to address the three basis values of the healthcare market, the system has approached this in a predictable fashion. What makes me think we are in the late phase of a mature market is the emergence of two types of innovations that are characteristic of this phase in this type of market. One addresses "customer intimacy" and the other addresses "operational excellence". According to Moore, a type of customer intimacy innovation seen in the late phase of a Mature Market is referred to as an "experiential innovation". It is the "ultimate refinement ...where the value is based not on differentiating the functionality but rather the experience of the offering." An example I see emerging in the primary care market of our healthcare system is the "boutique medical practice" that is becoming more popular. This is where a primary care physician limits the number of patients in their practice and delivers highly personalized care for each patient at a premium. Patients have 24/7 access to a highly qualified physician but at a cost. While this type of practice cannot be applied to the whole Healthcare System it does carve out a niche that is very functional for both the physician and patient who can afford it.

A Glimpse into the Crystal Ball

The other type of innovation Moore discusses looks at "operational excellence" where the "primary reward is a lowered cost structure that enables either price reductions, capital reinvestment , or higher profits." The specific type of innovation seen in the late phase of a Mature Market is referred to as a "value migration innovation". "The key principles of value-migration innovation are, first, to sense the erosion in value in the established roles, second, to anticipate where the migration of value is headed, and third, to get there before your competition." Moore notes, " migrates to cost-reduction enablers, maintenance providers, and outsourcers." I think this is already happening in the field of Primary Care with the introduction of such sources of services as MinuteClinic, QuickClinic and Medspot. These are clinics staffed by Nurse Practitioners and Physician Assistants who evaluate and manage a limited variety of relatively minor health problems. In the case of MinuteClinic they utilize a proprietary software system that assists their staff and guides medical decision making to ensure consistency. It can be considered just another phase along the road to our Healthcare System's evolution but I think it is also the beginning of something more radical. It is the first step toward what will ultimately lead to a disruptive innovation that will characterize the new emerging paradigm for our Healthcare System.

Say What?

All medical decision making will eventually be made through an interface that best utilizes the most up-to-date, state of the art health information. That interface, whether it be a human provider or a virtual reality provider will be networked to a system that has embedded within it a medical decision making protocol that when used exceeds the capabilities of a human functioning without one. I'll admit it remains to be seen if that is really the direction it will go but sooner or later it will either become more or less evident. Time will tell, but then again that is one of the key ingredients natural selection requires.

Tuesday, February 14, 2006

It's Time for a Universal Health Information Rating's System

Actually The "Rolls-Royce" of Rating's System

Last week the New York Times published a story titled "Low Fat Diet Does Not Cut Health Risks, Study Finds". It referred to an article published in the Journal of the American Medical Association (JAMA) which examined the associated health risks of a low-fat diet. Much has been said during the week about the article but what caught my eye was a comment by Dr. Michael Thun, who directs epidemiological research for the American Cancer Society. He is quoted as describing this study as "the Rolls-Royce of studies". While I'm sure most people would interpret this to mean "a very good study", it is not without its critics. The expression "Rolls-Royce" implies a very high standard, however most people do not know exactly what that range of that standard is. This is the problem with using such a descriptive phrase in an article which appears on the front page of the New York Times and is a lead article on its internet edition. We can do better and we have.

A Better Standard Already Exists

Most people are probably unaware that physicians and researchers do have standards to describe the quality of the evidence and recommendations that are used in medicine. It is a product of the evidence based medicine (EBM) movement that is rapidly becoming a more influential part of our Healthcare System. There are accepted methods to grade both the evidence and recommendations that are published. For instance, the Society of Critical Care Medicine ( as well as other notable medical societies frequently publish guidelines which are available on their websites. One such guideline, "Surviving Sepsis Campaign Guidelines" utilizes a modified methodology for its grading scheme. The evidence is graded best to worst (I-V) as well as any recommendations (A-E) promoted based on that evidence. What makes these guidelines particularly useful is that a reader can not only identify the source of each piece of evidence but also the standard on which to judge the strength of the evidence or recommendation. This type of ratings system is sorely lacking for the overwhelming majority of health information websites.

Is That Website You're Visiting HIT Worthy?

With more and more people flocking to the internet and using it as a source of health information, what assurances do any of us have that the information we obtain is accurate? The URAC (Utilization Review Accreditation Commission) is one that attempts to achieve a standardization process for this issue. The URAC is an organization that accredits health care organizations including health information websites. According to their website they update the standards for accreditation every three years. They require websites to: disclose sponsors and financial backers, identify how the website develops information, use evidence based information, have a quality oversight committee and maintain privacy and security standards. What having the URAC seal of approval on a website doesn't assure is that a grading of the evidence or recommendations will be provided as well. The quality of acceptable evidence can vary greatly. While URAC is a step in the right direction, bear in mind, so far they have only accredited just under 300 websites.

So Why is This Important?

In order to transition from the established paradigm of delivering healthcare to a new paradigm of delivering healthcare any prevailing source of health information must be reliable and trusted. As people seek the low cost and easy access of health information on the internet they will, in time, begin to demand that the available information is high quality and reliable. Most of these websites maintain an extensive "terms of use" that seeks to limit their exposure to liability, but as physicians discovered a long time ago with "consent forms" there is only so much you can do to hold back the tide of medical liability attorneys once there is a breach in the levee. There is an even more important reason to insist on a quality rating system for health information and that is because it can be a useful means to educate people not only on the existence of such a system but also on the widely varying array of quality that currently exists. There are simply too many snake oil salesman on the internet. There are guides on how to evaluate health information but I suspect most people choose not follow them very effectively, if at all. A simpler, more easily identifiable system is going to be needed as more and more people seek out the internet for health information.

Friday, February 10, 2006

Collapse & Our Healthcare System

The Three Main Reasons: Values, Values and Values

There is a quote in Jared Diamond's latest book, "Collapse: How Societies Choose to Fail or Succeed", that I think summarizes what I see happening in our Healthcare System today.

"That proves to be a common theme throughout history and also in the modern world...: the values to which people cling most stubbornly under inappropriate conditions are those values that were previously the source of their greatest triumphs over adversity." (p. 275)

The values of the established paradigm for delivering healthcare are conflicting with the values of an emerging paradigm for delivering healthcare. It is our insistence on maintaining those established values which is the source of some of our greatest conflicts in our Healthcare System.

Values vs. Values

Several years ago I repeated an exercise that I originally did almost fifteen years ago. This is how the exercise works. Take out a piece of paper and write down as many values as you believe are near and dear to your heart and soul. From that list choose twenty that you claim as your top twenty values. Take your time because this is really an important exercise. Let's call this final list of twenty your most cherished core set of values. Now take that list and rank them in terms of their importance to you. How I did it was to create a matrix with the value list written down one side of the paper and an identical value list across the top of the paper. Value by value compare them and make a notation on the matrix as to which value ranks higher. For instance compare health vs. security or love vs. success. When you have completed the list put it away for a period of time. In my case it turned out to be twelve years. It wasn't by intention, life just passed by very quickly during those twelve years. At the end of the time period pull out the original unranked list and repeat the same exercise. When I did it the results absolutely amazed me.

The Changing Value of Values

Remember to use the same list as the original, that is (was) your most cherished core values list. I figured some of the values might move around one or two places on the rank order of importance but I had no idea that some of my core values would move so far up and down. I initially created the rank list just after I completed medical school. It was a thrilling and anxiety laden time. The competition to do well in medical school was intense. Honors grades are sought out to insure matching in a better residency program. In the final two years these grades are primarily determined on how you perform on your clinical rotations. The approval of your senior residents and attendings is paramount. Looking at my value list from those days it was not too surprising that "approval" was on it. I'm still amazed how high I ranked it at the time. Twelve years later it dropped to the bottom of the list and in all likelihood would have fallen off had I not used the same list. In retrospect, "approval" probably was very important then, but my life is much different now. As I age I also noticed that "health" moved up on the list from its previous position. Integrity, honesty, freedom and trust remain near the top as they did for the original rank list. There are some values which are more resistant to change then others.

"I changed the most by not changing at all."
Eddie Vedder of Pearl Jam

Since that time I've gone on to further develop the list and discovered something interesting. I do have a core set of values that remains at or near the top of the list which are fairly constant and enduring. There is also a set of values that can change over time as my life circumstances change. They remain valued but their relative importance adjusts based on where I am at in my life. It is not that I didn't value "health" at a younger age. I did, that is how it got on the original list. It is just as I get older I value it even more and therefore relative to other values it rises on the list. As it rises on the list it guides the choices I make in life. (That is another way of saying those days of partying until the sun comes up are long since gone.) If you have any doubt about the relative value of values think about one of our major current political debates. Civil liberties versus homeland security. The 9/11 terrorist strike became one of those life circumstances that framed the nature of how we debate that issue today. Before 9/11 it would have been a different discussion.

Adapting to Our Future

So what does this have to do with our current Healthcare crisis? Everything, I think. It seems there is a constant stream of debate on this issue. Some have gone so far as to say our Healthcare System is going to collapse in the near future. I doubt this, but do believe that our currently established model for delivering healthcare is being transformed into a new model. The established paradigm is making way for an emerging new paradigm. What we are experiencing as a crisis is the heat and sparks caused by the friction of values passing each other on our national ranking list. It is not that we don't value those values that supported the established paradigm for delivering healthcare as it has done successfully for years, it is that we are coming to believe other values need to be more valued to support the new paradigm for delivering healthcare.

Monday, February 06, 2006

To Be Or Not To Be: Master Of Our Domain

Locus of Control in the Healthcare Crisis Storm

The problem with a paradigm shift is that by the time most people realize it is occurring it is already fully embedded itself into society. The Industrial Revolution is a prime example of a paradigm shift that occurred in western civilization that transformed us away from an agrarian society in a relatively short period of time. In the United States the majority of our society went from rural farmers to urban factory workers over the course of one century. From a historical perspective that is a blink of an eye. What if such a grand transformation is occurring today in our Healthcare System? Would we recognize it, and if we did what would be our response? Do we believe we are up to such a task?

Step 1: See the gathering storm in the distance

The first question we may want to consider is, "Is there a paradigm shift even occurring in our Healthcare System?" If you believe, as I do, that there is one occurring, and it is not obvious to the world, then we must seek evidence that such a shift is indeed occurring. If you do not believe one is occurring it is not incumbent upon you to provide proof that one is not occurring. Let's face it, paradigm shifts do not occur very frequently to justify a large number of people spending an undue amount of time chasing after proof of their non-existence. Proof of their emergence is therefore generally sought out by those who suspect one is occurring. There is one caveat for those who believe a change in the weather is not occurring: Don't forget to stow some inclement weather gear just in case.

Step 2: Prepare for a change in plan

If a paradigm shift was not occurring, could one be initiated and therefore radically transform a troubled Healthcare System? The examples of major paradigm shifts and the individuals who contributed to them are numerous (Copernicus, Newton, Einstein). The Industrial and Digital Revolutions were less any one individual and really more a growing series of individuals and groups who contributed to the changes that became essential for those paradigm shifts to occur. If one were to occur it would most likely occur in the fashion of the Industrial and Digital Revolutions. That is, over time and as a result of many contributions culminating in a radically transformed and improved way of delivering healthcare to our society. It can happen even if it is not happening. I just happen to be one of those who believes it is already happening.

Step 3: Design the best plan possible

If a paradigm shift is occurring and you recognize it, can you alter its course or modify its affects? That is, can an individual or a group exert an influence over the paradigm shift and shape its course? If you believe one can initiate a paradigm shift there is a tendency to believe you can change its course. What strikes me as curious in this attempt is that the concept of a paradigm shift has at its core the revealing of a fundamental truth that was not previously known. Paradigm shifts can also utilize available resources in a unique manner so as to transform the prevailing established paradigm. Altering it is best accomplished by understanding it better in order to improve it. To do otherwise is an attempt to bury it or to tarnish it in such a way as to hide it once again from society. I think this is why Thomas Kuhn proposed that a true paradigm shift is always different and better. If you believe you can alter its course, the time and energy you spend is better focused on improving the new paradigm. The substance of the debate is not over if it can be altered so much as what is the nature of the new paradigm and what is the best way to go about enabling and improving it?

Step 4: Act on yourself as well as your environment

The final question I leave for today is, "If a paradigm shift is occurring and you are caught in its wake can you alter or modify your response to it?" This is the essence of locus of control. If it is occurring and you have no control over it or yourself then you place yourself in the hands of fate. It therefore doesn't matter if one is occurring or not because you can't control it. (See advice under Step 1.) If, on the other hand, you feel a greater sense of control in the world, you will want to modify the paradigm shift and your response to it for the better. Proving a paradigm shift is occurring is only important to those who feel they have some control over what is happening in the world around them or at least how they will respond to it. So are you master of your domain?

Step 5: Leave the world a better place than when you arrived

The fundamental objective of a Healthcare system is to improve the health of that system's society. We are in the midst of a Healthcare crisis in the United States. There is a tendency to blame it on greed, incompetence and corruption of the individuals who contribute to our system. What I''m suggesting here is that our current Healthcare system has outgrown itself and is undergoing a transformation into a new system. The crisis happening before our eyes is the affects of an established paradigm of delivering healthcare struggling to sustain itself as a new paradigm for delivering healthcare is emerging . We can choose to see it or not. If we see it, we can choose to work to improve it as it emerges, or not. As we see it emerge and begin to affect us we can choose how we wish to respond to it, or not. If you believe you have a choice, those choices ultimately begin with seeing the transformation in the first place. We must start seeing the better system we need.