Hospital Beds: The Antiquated Metric

There was a time when the military was the role model for waste and backwards thinking, but in the last 15 years, the US military became a role model for lean optimization and innovative thinking. This new $451M healthcare facility at Camp Pendleton is an example-- only 62 hospital beds. Why? Because the whole motive of healthcare should be to keep patients out of the hospital with preventive care, and when necessary, treat them at home and in clinics. The military gets that. Says Lt Cmdr Stephen Padhi, "People always ask me, 'How many beds do you have?' That's an antiquated question." 

There are boatloads of commercial healthcare executives who, over the past 5-10 years, have continued to build giant "five star resort" hospitals, shrines to themselves and their outdated thinking. The railway executives in the early 1900s did the same thing with grandiose railroad stations that are now mostly museums, as the center of transportation in America shifted to the automobile and airplane.

Hospitals are not going to be the center of care in the future; hospital beds and inpatient treatment will be bought and sold as commodities on the stock exchange, while the center of care moves to ambulatory clinics and the patient's home.

Way to go Navy.  And that's from an Air Force guy.  :-)

Optimizing Cerner: Looking Back (Part 1)

Three years ago, I wrote the blog below to describe our intentions and aspirations for improving the current state of affairs for our Cerner applications in the Cayman Islands National Health System.

The phrase “EMR Optimization” is now the common term to describe our undertaking; fixing a very bad implementation is the more frank description. I half joked with full truth to my Cerner account team that they should have paid my salary.

A component of this optimization strategy included recompeting the existing Cerner contract. In part, we were motivated to recompete the contracts as a means for evaluating other options — to scout for greener pastures. Aside from that, we were required by government policies and regulations to compete the contract upon its expiration. Eight vendors submitted responses to the RFP:  AssistMed, Cerner, IBM/Alert/Stockell, Keane, MEDITECH, Populus, RazorInsights, and Siemens.

In my next blog, I will summarize the journey of that optimization and recompeting the contract. For now, here’s a repeat of that blog from three years ago. In the blog, CayHealth referred to our version of what amounts to an Accountable Care Organization.

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Cerner and the Cayman Islands (June 2010)

The Cayman Islands purchased Cerner Millennium (PowerNote, CareNet, PathNet, RadNet, PharmNet) and ProFit financials in 2005, before I arrived as CIO. Both Cerner and the Cayman Islands have been struggling ever since to make the implementation a success. For the most part, the clinical applications have been relatively successful, even though the physicians are reluctant users; data access and data analysis is torture; and the implementation lacks many added-value features — notably medication order entry.

The ProFit implementation has been only slightly less than a disaster. Practicing medicine is, for the most part, a fairly consistent experience between the US and Cayman Islands, but the Caymans are considerably different in their management of financials and interactions with insurance companies. Cerner admits now that ProFit was a misfit, and we still have a long way to go to make it reliable and functional.

To Cerner’s credit, Talbott Young, the VP who covers the Latin American Region, and Lisbeth Fabiny, our Customer Results Executive, are phenomenal partners in improving the value-add from Cerner products in the Cayman Islands. Neither of them was involved in the initial implementation or contract, so pride of ownership is not an issue.

In my first eight months here, we (my IS team and I) have been focusing on remodeling the neglected technology infrastructure — basic issues like antivirus software, new desktop computing, new printers, cabling, networking, data backups, etc., have kept me very busy. But in the next few months, I will start to climb my way up the technology stack and focus more on the data content and application configuration of Cerner.

Improving the cost-benefit ratio of Cerner is my prime concern. We spend almost $3M per year in Total Cost of Ownership on Cerner, which consumes about 90% of our IT budget. Our IT budget accounts for 4.5% of our total operating budget for the health system, which is much too high, especially given the lack of perceived benefits from Cerner. Our Cerner TCO equates to an overhead of about $41K per employed physician per year.

The Role of Cerner in the Success of CayHealth

If software functionality and design is a reflection of the processes it supports; and if we all agree that our US healthcare process is flawed, then Euclid would conclude that the functionality and design of our current crop of EMRs is also flawed, and Cerner is no exception. In order for CayHealth to be successful, we must partner with Cerner to make some fundamental and major changes to their products’ implementation in the Cayman Islands.

Like all market-leading EMRs in the US, Cerner’s products are a reflection of a healthcare documentation application — not a healthcare delivery application. The design of Cerner was fundamentally motivated by a US market driven by:

• Defensive Medicine: Protecting the physician from spurious lawsuits and billing compliance violations.
• Maximum Billing: Documenting care in such a way that it aligns with the insanely complicated billing rules in the US, but yet also ensures the highest level of payment for services rendered.

We have the opportunity in the Cayman Islands to reengineer our Cerner EMR and surrounding ecosystem so that every mouse click, every function, and every user interface will support and be judged by its contribution to a different set of motives with more sensible origins, including:

Next Generation of EMRs: Improved Motivations of Design

1. Clinician Workflow Efficiency: Enabling clinicians to practice the best medicine possible, in the least amount of time and lowest risk.
2. Evidenced-Based Medicine: Patient-tailored and dynamically generated follow-up appointments, order sets and patient health optimization plans.
3. Economics of Care: Informing the patient and the physician of Total Cost of Care–to the patient and the insurance company–at the point of care, so that treatment options can be discussed within the context of cost and benefit.
4. Patient Engagement: Enabling patients to be more involved, if they are capable, in their own healthcare through personal health records, social networking support groups, financial accountability, and patient-specific health optimization plans.
5. Patient Safety: Providing user interfaces and decision support that enhances the delivery of safe medicine.
6. Paperless transactions: Among clinicians, patients, employers, and insurance companies.

In Part 2, I’ll report on the procurement and progress of the optimization, in particular our headway towards the aspirations listed above.

Patient Satisfaction and Outcomes Data: Glaring Omission in Healthcare

The New England Journal of Medicine recently published an excellent article on patient satisfaction and outcomes data. ("The Patient Experience and Health Outcomes").

My Toyota maintenance guy sends me a customer satisfaction email automatically after each "clinical encounter" with my cars.  He asks me to rate the quality of the service he provided as well as the quality of the outcome ("Did we fix your problem?") and the cost effectiveness ("Do you feel that our prices were fair, clearly explained beforehand, and understandable?").  Toyota corporate offices review these results in detail and they hold those dealerships totally accountable, with consequences for bad numbers. You would think that the functionality of EMRs that cost $$$$$ millions could at least match my Toyota maintenance guy.

But in healthcare, we're different.  For one thing, our software is designed around 1970s engineering practices and technology, but more importantly, we hold ourselves in a self-appointed position of superiority.  Our patients are not medically qualified to understand the "true" quality of our God-like work.  In the afterlife, the mystery and complexity of our services will be revealed to you, so for now, don't bother your simple little head.  Just trust us that we are great, regardless of what you might think.

As a business person and a CIO, the only two metrics that really matter to me are employee satisfaction and customer satisfaction.  As fellow CIOs can attest, we are inundated with metrics.  Managing a complex IT environment in a healthcare setting is like surfing in a hurricane of metrics, at every layer of technology that we manage, from the data center to the software application.  But... the only two metrics that really matter are employee satisfaction and customer satisfaction.  Every other metric is a means to those two ends.

The reality is, in healthcare, we're chickens.  We’re afraid to ask the patient what they think of our services and treatments, and we veil that fear in false claims of complexity and scientific validity.  In the world of psychology, we perpetuate the "illusion of validity".  In the words of Jack Nicholson in a Few Good Men, we can't handle the truth, so we avoid the vulnerability.

On a practical level, the current (and misplaced) love affair we have with predictive analytics in healthcare is little more than a teenage romance novel without patient satisfaction and outcomes data.  Why are readmissions the current focus of predictive analytics?  It's a bona fide problem in healthcare, true, but it's also the only patient outcome that we can reasonably measure-- we know with data as evidence that the patient has been readmitted.  We don't have the clinical outcomes data to predict anything else.  In terns of knowledge based software design, we don't have a "training set" to teach our predictive algorithms.  Good luck to good old Watson at IBM.  Without patient outcomes, Watson won't know what works and what doesn't work in healthcare.  And the satisfaction surveys that sample a portion of our patients 90 days after an encounter?  Those don't count.  They are anonymous and almost never tied back to specific care providers and treatment protocols.

Credit to the NEJM for bringing this topic to the front of discussions.  Let's hope that healthcare CEOs in clinics and hospitals will face the truth and start following the culture of Toyota.  Ignore the pundits who claim that patient satisfaction is too complicated to measure.  Build a survey that passes the common sense test to you, and then insist that your EMR vendor enable its automatic dissemination and integration with your clinical data.

Piedmont & WellStar Broaden the Data Ecosystem

Piedmont and WellStar are creating their own insurance company.  Hopefully, this trend will take off and we'll see a significant disintermediation of third party insurance, like Blue Cross and United, and insurance company profits can thus instead be channeled back into the healthcare delivery organization and a portion of those profits can be redirected as dividends and returned to patients-- the stockholders in healthcare.   Here's the article in The Atlanta Journal-Constitution.

Piedmont and WellStar's decision is a great step towards a common sense ACO, without the crazy overhead and complexity of a federal ACO. If you look closely, the most respected and revered healthcare delivery organizations in the US include their own insurance company under a single, overarching CEO who balances care delivery with economic affordability and risk management towards quality of care, not volume of care. Those CEOs, like Charles Sorensen of Intermountain Healthcare, are "accountable" for balancing healthcare quality in hospitals and clinics with healthcare economics in the insurance company.

Note, at the heart of this business strategy is DATA. In order to fully manage a patient's healthcare in an accountable manner, healthcare delivery organizations must expand the data ecosystem that are available to them for analysis. Claims data is one piece of that ecosystem, along with inpatient clinica data, outpatient clinical data and eventually, patient reported data, particularly outcomes and quality of life data, which is largely missing in today's healthcare analytics environment.

Compliments to the leadership teams of Piedmont and WellStar. Let's hope other healthcare executives that fancy themselves as leaders, will follow. :-)

The Value of Mentorship

Excluding my father, who was a great mentor, but unfortunately departed this world too early to mentor me professionally, I’ve only had one mentor in my life. And I emphasize ‘only’ because it’s sad that we don’t have a culture that encourages mentorship until the day we die. It’s worth noting, some people are not willing to be mentored; and some people who claim or aspire to be mentors, are motivated by delusions of self-grandeur. In the Air Force, they assigned a senior officer as a mentor to me when I was a lowly lieutenant, but he was more concerned about impressing me than improving me.  And there’s a difference between a role model and a mentor.  We are surrounded, gratefully, by the former, not so lucky with the latter.  The mentor is a role model, but also spends selfless one-on-one time with the protege.  That personal attention and coaching is priceless.

Ron Gault was my mentor at TRW Space & Defense when I transitioned from the Air Force to civilian life. He was not a mentor by formal title, but rather by his role model behavior. By title, he was my supervisor and boss. Ron became my mentor because he behaved in a way that endeared me to those behaviors. I wanted to be more like him and wanted to treat people the way he treated them.

He advised me, he encouraged me, and he allowed me to make non-fatal mistakes. He gave me the freedom to be myself and allowed me to pursue crazy ideas, some of which were fruitful and some were not. He fostered humor at work and exhibited selflessness at every opportunity. He indulged my rebellious nature. He put me and other members of our team in the spotlight when it was more common for other supervisors to occupy the spotlight or take credit for success themselves.

He exhibited a constant sense of curiosity and passion for learning that rippled out to all of us. He role modeled the old school habits of hard work and complete reliability — when he committed to something, he lived up to the commitment, no matter how hard it was to do so and how much effort it took. He reinforced the notion that, if you nurture interpersonal relations at work and with your clients, the quality of your work will be high, as a natural outcome.

In the end, his mentoring didn’t stop with me. He made me appreciate the value of mentoring so highly that I’ve tried ever since to live up to what he did for me with my mentorship of my teams at work, as well as with my nieces, nephews, and friends’ children.

The nice thing is, even though we don’t work together directly any more, he’s still my mentor. He’s still the person I call first when I have a perplexing problem, personally or professionally. If I could just get him to be a better horse rider at getaway speeds, he’d be perfect. (That’s an inside joke about our oft referenced movie, Butch Cassidy and The Sundance Kid.)

There are a handful other people that have blessed my life with the behaviors and wisdom of mentorship — Jim Adams of the Advisory Board, Denis Protti of the University of Victoria British Columbia, Dr. David Burton, Al Pryor, and Larry Grandia of Intermountain Healthcare, and Dr. Jim Schroeder of Northwestern University Medical.

But the influence of their mentorship couldn’t match what Ron provided. The bond of Ron’s mentorship was forged on the anvil of some very exciting and challenging projects at TRW that would be very difficult to replicate, and it came at a crucially young time in my professional life when the future was still maleable and success uncertain.

Unity

This post has very little to do with being a healthcare CIO or executive of any kind... or does it?  If you occupy a position of leadership, you are responsible for creating unity, all around you.  While complete unity may not always be possible, as a leader, you must always strive for it.  But we can't always rely on leaders, elected or appointed, to be the role mode for unity.  It starts with each of us.

The man we elect President tonight can do little more than act as a role model-- good or bad. Absent his role as leader of the US military, he can do very little, and even that role can be usurped by Congress. So... it makes little sense to be consumed with opinion about winning and losing, and further alienate one another. We are the UNITED states. The accountability for the dream and role model resides in each of us. Do we reach out with an arm around the shoulders of those next to us, or turn our back to them? Do men protect women, children and the invalid, or do we prey upon them? Do we cheer in good sport for the opposing team, or celebrate their injury? Do we find wonder and curiosity in different religions, races, and cultures, or do we find repulsion? Do we exploit or respect? Do we enslave ourselves in chains of greed or free ourselves in the winds of benevolence? We need to stop living as if the better answers reside in the identities of those we elect.

Tomorrow morning, wouldn't it be refreshing if we didn't talk about winners and losers, but rather unity and individual accountability for realizing the dream?

By the way, I'm a die-hard political independent and generally distrust both political parties. :-)

Are You Lovesighted in Business?

Lovesighted: A metaphor for nearsighted and/or farsighted, wherein the victim fails to see the reality of a situation because the better logic of their mind is overcome with the emotional love of self, love of their own ideas, or love of another person. Can also apply to companies and industries who fail to see the reality of their changing market because they are emotionally attached to traditional business models. Frequently affects teenagers, mothers, and CEOs in healthcare and automotive manufacturing.

:-)~

(Rikki Lynn photography)