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.
Monday, February 27, 2006
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.
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, "...it 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.
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, "...it 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 (SCCM.org) 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.
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 (SCCM.org) 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.
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.
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.
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