Saturday, February 24, 2007

Health Care System 2.0: Surrogate Providers

Trial and Error

The mechanisms by which we will transition from an established platform for delivering health care (Patient-Physician relationship) to an emerging platform for delivering health care (Patient-Information Technology relationship) are not new. They are just new to patients and physicians within the context of their current relationship. Both groups are moving outside their comfort zones to test the alternatives that are becoming available. Learning through trial and error is in the nature of human beings. As we learn, we incorporate new information and blend it into the existing network of information. Moving from one paradigm to another happens the same way. It is gradual right up until the time it isn't and then it becomes obvious to everyone. The transition has already begun. The change is already happening at the most fundamental level. This is in the nature of the Patient-Physician relationship. It has become a Patient-Provider relationship and even the nature of the Provider is changing.

Non-Physician Providers

There are more sources of Providers available today than ever before, and many of those sources are becoming more readily acceptable (Retail Clinics, Chiropractors, Nurse Practitioners, Physician Assistants, Advanced Practice Nurses, Medical Spas). The Internet and television have also become valuable sources of health care related information (Google, Pub Med, Web MD, Dr. Gupta). Many of these options are based on ideas created by physicians but this is not true for all of them. Physicians are also breaking out of their mold. Not only are they offering alternative methods of accessing health care information but they are developing the fundamental concepts for the basis of these information warehouses. Often this comes in the form of protocols and guidelines but it can also be in the form of an IT based evaluation. When the established paradigm for delivering health care was at its peak it was the physicians who were the primary gatekeepers of this type of information. Patients could only access this storehouse of information and services directly through contact with a physician. Times are changing and people no longer have to do this. So why is this?

What People Want

It is no secret that people want three things from the health care system. They are access, quality and low cost. Physicians are slowly beginning to realize this and are struggling to achieve these "customer demands". As they do this they must compete at a different level. They must use alternative methods of delivering health care services and they must begin to deliver them using the older established platform for delivering health care. This traditional platform for delivering health care is relatively slow to perform in this on-demand world we live. So how do we transition from the established platform (Patient-Physician) to the emerging platform (Patient-IT based Provider)? It will be through a series of surrogates.

Surrogate Providers

Surrogate Providers come in two forms. One is human the other is technology based. Access to medically related information is the starting point for both types. The human form is represented by the non-physician providers of health care. Examples include Nurse Practitioners and Physician Assistants. In recent years we have seen the growth of Nurse Practitioners and Physician Assistants who are also providing needed information and services. They do it with improved access and lower cost. Some may argue that the quality is not up to par with that of physicians but the people paying for these services tell us something different. The growth of the retail based clinics such as Minute Clinic demonstrates that people approve of them and think they are of value. The Nurse Practitioners and Physician Assistants who staff them use an algorithm base artificial intelligence to guide their decision making. As retail based clinics expand they will confront greater competition to deliver more services, maintain access, improve quality and drive cost down even further. In time even the Nurse Practitioners and Physician Assistants will find they have competition.

Built To Last

It is the other form of non-physician provider that will be the main form of competition. This is the information technology based provider. Currently it is in its most immature state of existence. As technology improves and medical information systems become more advanced they will begin to compete with the human forms of providers. Initially they will augment and support human providers but in time as people begin to trust IT based support they will seek out the IT based provider. An IT based provider will be available 24/7. It will have all available information regarding the patient, their health related problem and its treatment. It will constantly be up to date. It will cost substantially less than any of the current forms of providers. The day will come when we will have virtual reality environments that will simulate a Physician for those who wish to interact with a visual entity. What is amazing is that I think it will ultimately be physicians who usher in this era. Why is that you say?

Self Interest & Survival

There are two reasons. The first is because it will deliver a better Health Care System. That is Health Care System 2.0. It will deliver better quality care, with improved access to care and at a lower cost. The second reason is because physicians will see it as in their best interest. Retail based clinics are a form of low end disruptive innovation. As they mature they will carve out more and more of the role that physicians have traditionally maintained. This is, as distributors of medical advice and as gatekeepers of the health care system. The IT based providers will in time act as a disruptive innovation and carve out more and more of the retail based clinics territory. Both of these entities have and will continue to have limitations. Each of these types of providers have algorithms that have exit points. These are decision nodes that refer the patient to a physician or other human provider for a specialty service. It will be in the best interest of physicians to position themselves as the natural selection for those referrals. For most physician specialists it will be immaterial who refers them patients. It won't matter if the gatekeeper and referral source is human or IT based. For the patient with an IT based provider they will know instantly who is the closest physician specialist, what is their availability, how much will they cost and how do they compare with other specialists in their field of expertise. In order to compete physicians will need to participate in systems that will optimize their access, cost and quality of care. Everybody keeps clamoring for transparency in our Health Care System. The only transparency that will be needed is that related to access, cost and quality. Beyond that anything goes in Health Care System 2.0.

Sunday, February 18, 2007

Mass Customization & Evidence Based Medicine

Mass Customization

A couple of weeks ago I became reacquainted with the concept of mass customization. Mass customization "is the use of flexible computer-aided manufacturing systems to produce custom output. Those systems combine low unit costs of mass production processes with the flexibility of individual customization." Raised the son of a car dealer I spent my youth on the showroom floor and saw for myself how a basic model of automobile could be customized with options to suit the needs and wishes of the customer. Most of the components of that vehicle were the same as any other of that model year. Details such as the color of the car or type of wheels were customized and that is what was used to close the deal and sell the vehicle. Today industry leaders such as Toyota have worked continuous quality improvement into the process of automobile manufacturing with stunning success. The computer industry has capitalized on this concept as well, most notably Dell Computers. Any individual can order a model of computer and customize it with the options that they want. The computer, just like a vehicle at Toyota is then built with "just in time" manufacturing processes that improve the efficiency of the process and decrease the cost. The idea is to get "the right material, at the right time, at the right place, and in the exact amount." It got me wondering if a variant of this concept could be used in the development and implementation of evidence based medicine.

Evidence Based Medicine

Evidence based medicine (EBM) is the idea of using the best available evidence to guide the clinical practice of medicine. While this may seem obvious it is not always as standardized as we may think. There still remains a significant bench to bedside gap. What this means is that medical research discoveries may take years to decades to find their way into the textbooks and everyday practice of clinicians. EBM is a movement in medicine to reduce that time period and bring the best available medical treatments into the care of patients today. It is easier said then done. While physicians are some of the greatest champions of this movement they are also one of the biggest obstacles. The development of EBM typically distills a large mass of evidence down to a single standard or guideline. Physicians tend to be suspicious of guidelines and consider them too rigid when applied universally. They see it as a "one size fits all" approach to the care of patients which is contrary to their every day experience. Most physicians see their value, not only as gatekeepers to the health care system but as the ones who will customize and tailor the treatments available in medicine to the individual patient. EBM and its guidelines removes this customization process and therefore one of the roles of the traditional physician. EBM then becomes a threat to the livelihood of the physician. There has to be a better way and I think there is.

"The only thing we have to fear is fear itself."
Franklin Delano Roosevelt

The idea of improving the process of how we deliver health care is not new. Total Quality Management has been around for years but not exactly embraced by physicians. Again there is a deep suspicion that this will remove any customization the physician will provide but more importantly may introduce an element of risk for the physician. The transparency advocated by this process and the emphasis on exposing errors brings with it the fear of medical liability litigation which has become such a dominant part of the health care landscape over the last several decades. How do we overcome this barrier and create a process that decreases or even eliminates this all to real fear? I think it may come in the form of a variant to mass customization which could be called "evidence based mass customization". I think it will take courage to implement because it depends on the process of error reduction advocated by supporters of Root Cause Analysis and Six Sigma. With the focus on error reduction comes the hazards of error exposure but in this case the benefit is worth the risk. It can be argued that reducing error will ultimately contribute to the reduction of medical liability risk. Staying within the guidelines may decrease the freedom of physicians to customize what treatments they prescribe but should also bring with it the decreased likelihood of lawsuits. This remains to be seen but it is the hope of those who believe in guidelines. So how do we get physicians to buy into this when there is no guarantee that they will reduce medical liability?

Evidence Based Mass Customization

In medicine we know that when a specific practice pattern has increased variability it also carries with it an increased likelihood of error. We also know that as we reduce the heterogeneity of our practice patterns and focus on a "best practice" we reduce the likelihood of error. Health care guidelines are, in essence, a set of rules for how to approach a specific medical problem. They are evidenced based rules and have been shown to reduce variability in practice patterns and to reduce errors. It seems like the perfect solution and yet there is resistance. Physicians all to often see the exceptions to the rules and therefore are hesitant to endorse the broad application of guidelines. What we need then is a way to customize guidelines in the daily practice of medicine. Most of the time guidelines, when properly designed, work for most of the patients. Mass customization would mean creating guidelines that would have universal application for 90-95% or more of the time they are needed. The remaining 5-10% of the time would default to a physician who would tailor the treatment to the specific need of their patient. Another way to design them is to create guidelines that could be used, as written, at all health care institutions. Variations to the guideline would depend on local health care resources. An example would be of a guideline that results in the prescription for a specific class of a medication. The specific medication prescribed in that class would depend on things such as local prescribing habits, approved hospital formulary medications and insurance limitations. The way to sell guidelines is to leave room for the options. Most physicians are willing to work with guidelines as long as they believe they can customize them in a way that meets the needs of their patients. The key is to design guidelines that create a feedback loop back to both the creators of the guidelines as well as those modifying them at the patient level. Without a feedback loop neither will be able to continuously improve the guidelines or the way they are being modified. The advantage of leaving room for minor variations is that these variations will inevitably identify further modifications and improvements to the original guidelines. The goal is to get the right treatment, at the right time, to the right patient with the best possible outcome.

Sunday, February 11, 2007

Health Care System 2.0

The Time Is Now

Everyone agrees that our health care system is in need of serious reform. Some go so far as to say we need to transform our health care system. I have some different ideas on this subject. I don't think we need to look to the future for the transformation of our health care system. I think it is happening right now. This is it. This is what it looks like and feels like. We seem to think it is going to be some type of pleasant experience. It's not. It is this way because we must simultaneously dismantle the model upon which the established paradigm of delivering health care is built and replace it with a new model upon which the emerging paradigm of delivering health care will become established. It must do this and continue to deliver health care to our society. It is not an easy task to do but I believe this process has already begun.

The Gatekeeper

The established paradigm of delivering health care is based on the classic patient-physician relationship. Let's call this paradigm Health Care System 1.0 to borrow a software version analogy. What we have witnessed over the last forty years has been an unprecedented attack on this relationship. Much of it has focused on the role of the physician as the primary gatekeeper to the health care system's vast resources. Most if not all major consultations, prescription medications, in-patient and out-patient treatments and operations were accessed by first going through a physician. If you need anything available in Health Care System 1.0 you must first be granted access by a doctor. In version 1.0 this made sense. The doctors education and training was an essential element needed to direct the patient toward the best available resource. It was the doctors experience with version 1.0 that helped guide the patient through this complex-adaptive system. So where is the evidence that this relationship is under attack or even strained?

Under Pressure

The patient-physician relationship is experiencing multiple sources of pressure. Reimbursements for physician services continue to be cut or at least not increase in a manner to keep up with the cost of living. The rise in medical liability rates has also created a pressure by increasing practice expenses. This means that each patient contact results in reduced net payment to the physician and an increased exposure to medical liability risk. In order to maintain the same level of income a physician must gravitate toward contacts with either reduced risk or improved reimbursement per contact. In addition, insurance companies want a greater say in what treatments a patient may undergo or what medications they may be prescribed. This increases the "hassle factor" for physicians struggling to match allowable treatments and medications with what they believe to be the standard of care. What is slowly happening is the role of the physician as gatekeeper is being stripped away. The combined effect of decreased reimbursement, increased expense, increased medical liability risk and outside sources directing medical care is passively conspiring to remove physicians from this role. Hear me out, I said remove physicians from this role, not entirely remove physicians from the Health Care System. So who or what will assume this role?

Design Specifications for Gatekeeper 2.0

Clayton Christensen touched on this in his recent book, Seeing What's Next. I referenced this source in a previous blog addressing disruptive innovation and trauma centers but it's worth repeating because it really focuses on how this process is currently progressing. He summarized this in the chapter titled "Healing the 800-Pound Gorilla".

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) Non market forces affect the market for innovation by influencing industry players motivation and ability.

I believe as we get better at defining the rules and integrate them into our growing network of information technology these will become the protocols and pathways used by the less-skilled people. This is already in place for mid-levels practicing with Minute Clinic. The protocols and pathways will need to be stored in a platform that can access the information at all times. The artificial intelligence built into this platform will guide the mid-level and eventually even less-skilled people through the maze once only entrusted to a physician. It will need to do this in a way that improves health care access to the patient, at a lower cost with "as good as" results. Minute Clinic and its copycats are already doing this for relatively minor health problems. As they get better at this process they will inevitably migrate up the value chain.

Summer Is Coming

So am I for it or against it? I am neither. I see it as inevitable. It would be like asking me if I am for or against the coming summer. Since I live in Phoenix, Arizona it would be like asking me if I endorse one hundred and fifteen degrees in the shade? I don't really endorse it one way or another I just prepare for it if I plan on being here in the summer months. Between now and then the average daily temperature will slowly rise. It doesn't happen all at once but a little bit at a time. I see the coming of Health Care System 2.0 the same way. I guess in some ways I endorse it because I hope it really will deliver on the promise of an improved Health Care System. Either way, just like the coming summer, I plan on preparing for it by adapting to the daily changes.

Saturday, February 10, 2007

Trauma System 2.0

Health Care System 2.0

There is an evolving change happening in trauma systems that is occurring within the context of our "Health Care Crisis". Before I discuss this any further I need to remind you of the original concept of this blog which describes, what I believe is, this greater context. I've discussed this previously but let me summarize this idea. What we are experiencing as a "Health Care Crisis" is really the emergence of a new paradigm for delivering health care. The established model of delivering health care was built on the idea of the Patient-Physician relationship. Physicians acted as gatekeepers to the services, accumulated knowledge and experience of the health care system. The nature of this relationship is changing. It is evolving into a Patient-Provider relationship where the "Provider" will be an information technology based platform that uses artificial intelligence for delivering health care. What we are experiencing now as a "crisis" is the deconstruction of the established paradigm, the conserving of the essential elements of that paradigm and the building of a new model on the foundation of the older model. If you are wondering where the deconstruction is occurring look no further than where everyone is pointing to as the cause of the crisis.

The Prime Directive

Not a day goes by when someone in the popular media is not commenting on the health care crisis. We hear it all the time. "The system is collapsing." "Medical costs are spiraling out of control." "There are over 45 million Americans without health insurance." "Greedy trial lawyers are suffocating the health care system." "Insurance and pharmaceutical company executives are profiting off of the sick and dying." The list goes on and yet amazingly despite these complaints medicine on the whole continues to improve. How does that occur? The reason is because the system was designed to improve the health of our society over time. That is the prime directive. It says nothing about how we will deliver that directive. It is only concerned with improvement over time. If that means disrupting a time honored delivery platform to replace it with one that is fundamentally better than so be it. This will and is affecting all sub-systems of Health Care version 1.0.

Trauma System 1.0

The latter half of the 20th century saw the dramatic development of trauma systems and the improved delivery of health care to the acutely injured patients. It took the bold actions of Trauma Surgeons such as R Adams Cowley, MD to advocate for those systems. He and others of his generation identified the need for Trauma Centers and impressed upon the leaders of the time to implement such systems. While slow to develop these systems have proven their worth to our society. These systems were primarily established through the hard work of those who worked in the trenches, so to speak. They are the surgeons, emergency medicine physicians, nurses, paramedics, emergency medicine technicians and all other clinical personnel who evaluated and treated the people injured by traumatic mechanism. In time these professionals created societies and networks for the physicians, nurses and allied health personnel. This allowed for greater improvements in the delivery of trauma health care. There are limits to this process and I believe we are approaching them.

The Trauma Club

The people who work in trauma tend to be a tight-nit group. It is a very small club and there is a belief that if you have never done time in the trauma trenches then your opinion doesn't matter. We're the insiders and all others are the outsiders. While this sense of camaraderie and control was essential for the establishment of trauma systems I believe it may be the very factor that is holding back their further development. Trauma Surgeons are the main gatekeepers to the definitive treatment centers for trauma care. As we continue to improve we have become victims of our own success. It is an ironic twist of fate that as a Trauma Surgeon gets better at what they do, they tend to do less of what they were originally trained to do, which is surgery. The majority of the trauma patients in the National Trauma Data Bank (NTDB) have minor injuries as measured by the Injury Severity Score (ISS). It is becoming increasingly obvious that not all of those patients need to be evaluated by a Trauma Surgeon. The ones who benefit the most from the services of a Trauma Surgeon are those with more severe injuries. In order to direct those patients to where a Trauma Surgeon is requires a highly developed Trauma System. Taking the current systems to the next level to meet those needs is going to require Trauma Surgeons to give up something they worked so hard to get. That is, control of those systems.

"A man must not deny his manifest abilities, for that is to evade his obligations."
Robert Louis Stevenson

We have gotten so good at what we do we have forgotten what it is that we don't do so well. Trauma Surgeons are leaders in the trauma room and operating room. We make difficult decisions often based on little information which can directly affect the life of our patients. We perform regularly and successfully under stressful conditions. It's a small world we live in. We're distrustful of outsiders and certainly don't wish to allow others to control our destiny as society so often grants us the privilege to do for it on a daily basis. What we don't do so well is run large scale operations of the system type. There are others, particularly in the world of business, who are much better at doing that. They understand and work on a daily basis with the concepts of "complex systems architecture", "disruptive and sustaining innovation", "economy of scale" and "value chain". Ideas such as these are essential for understanding the way organizations progress and succeed. Trauma systems are at the threshold of a new type of delivery system. They need strong leadership of a different kind. The kind of leadership needed is one which has experience at running large complex systems. Trauma Surgeons will need to make some decisions. They can go back to doing what they were trained to do. They can recruit others from outside the club to run these systems. Or they can venture outside the club walls and seek the education and training it takes to manage these systems. One way or another Trauma System 2.0 is coming. It will be built on the conserved essential elements of Trauma System 1.0. While version 2.0 may diminish the role of the traditional Trauma Surgeon, let us not forget that the leaders of it will be standing on the shoulders of those giants who built version 1.0.