Think ATMs

California's TeleHealth project (InformationWeek) that has the potential to link providers in 900 hospitals in California is an amazing step forward for streamlining healthcare and creating greater access to quality.  Just beginning, it holds the potential to decrease unnecessary testing, tap experts at other centers and stretch resources across the California healthcare landscape.  The result, hopefully, is reduced cost and greater quality.

But what after California?  Is this a state-by-state system ? Or like the banking systems that allowed access to your own financial information through ATMs almost anywhere in the US and often abroad, is it an integrated standardized system?  The National Health Information Network is the long term goal although it appears to be happening state by state.  This makes the investment in hospital and physician technology critical and daunting for smaller hospitals and primary care physicians, as stand alone banks a few decades ago found out as the banking system became national and multinational.  But the Federal government has created Regional Extension Centers (RECs) to support 100,000 primary providers in 2 years.

The possibilities are out there.  Broadband technology is in use organization by organization but what is next for the system.  How far can we go to access our health information?  And which states will follow California?

Evaluating capital decisions in the new era (AR:after reform)

I am dating myself but I went to school when 2011 years ago was BC.  For my newly educated almost adult children BC is BCE(Before Common Era) and AD is CE (Common Era).  I don't know what is so common about it, but I digress.  So I am calling this new health era that we are in 1 AR (after reform).  I think it is better than AO (after Obamacare) because I find that title somewhat awful! (You could also call it After Recession, but I am not sure we would know when to start counting.)

So in this new time, how will decision-making processes change for CEOs and Boards.  OR should they? Especially on big strategic investments and overall capital spending. 

Is it a time to continue status quo and build a better mousetrap?  Or is it time to retool (think auto companies, but they had a bailout)?  Or is it all in IT and infrastructure?  What are you doing with bricks and mortar?  How are you tying these decisions to the overall economics and demographics of your community? 

Only three short years ago, the capital race to build it better than the guy down the street was on full tilt.  More new hospitals went up or were on the drawing board with little change in business plan.  Yeah, there were a few that were creating the ER for bioterrorism, or were going green but in terms of the basic hospital model of inpatient care at 4.6 days LOS, not much was changing.

As discussions of consolidation, community health centers, accountable care organizations and networks loom, how is it affecting capital decision-making?  Is your capital assessment strategy the same (cutting edge, tried and true or whatever level you were in BR (before reform and recession).

As the medical cost index dipped for only the 6th month in 63 years, is it a bleap or a new era?

What should your board be asking? 

1. What does this technology do to tie the patient into the system longer term and help manage their care? 
2.  Is this redundant in the marketplace and can we be the best at it when the scorecards come out? 
3. How will we use this investment to reduce operating costs?

Investment in the independent hospital unless you are the sole community provider seems to be premature at this point.  Opportunities to expand ambulatory facilities, virtual care through internet, smart phones for doctors, fully integrated EHR may be how you differentiate in this era.  Investments in safety features, outpatient labs, inhome monitoring capability of chronic patients may tie those patients to your facility more than the shiny tower. 

In looking at the assessment strategy, only those with major research capabilities should be jumping in to alpha and beta site new technology.  The proven workhorse that can sustain your organization longer term may be the better investment, regardless of the EMR incentives from Medicare.

When we look back from 10 AR what investments will have made the difference?  And which were a waste?

Making it work for less

The article in USA Today documents the need for payment to physicians for phone and email contact with patients.  http://www.usatoday.com/news/health/2010-08-16-1Aprimarycare16_CV_N.htm?loc=interstitialskip
I would take it one step further and suggest that primary care physicians that check in with all the subspecialists on a complex patient should get paid for that communication too.  The result, better care, lower cost, BENDING THE COST CURVE for most patients.

The article also highlights those practices that didn't wait til the payment was just right to start doing the next best thing.  They did what they needed to do to prove their model works.  How:  transition plannning.  They enlisted their patients in paying a fee for the model.  Might not work everywhere but managing the transition is going to be the big issue for all practices big and small.

Small changes make big differences in safety and cost

Another fascinating study by the U of M.  Not only did they prove that reminder systems that cut through the human error/red tape conundrum work for reducing Catheter-aquired UTIs but they went on to study whether the Medicare regs meant to encourage this kind of activity served as an incentive. http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1683. What did they find?  That their system, especially computerized reminders at log-on and empowering nursing to make a catheter removal decision decreased infections by 52%.  This is important for other common hospital acquired infections also.  Even hand washing reminders could pop up at log-on!  But sadly only 1 in 10 hospitals currently have these systems in place.

But what I found fascinating was the second part of the article that the Medicare regs while appearing to be an incentive to change behavior, in actuality had no economic impact because most hospitals don't document these properly.  So the hospitals that don't change really won't be effected.  You can blame the Medicare bureaucrats, but I bet the hospital management at most hospitals had no idea how they bill for CAUTIs.  (I for one didn't!)

What is the lesson?  The lesson should be that these ideas are the saviors of the healthcare system because they will allow hospitals to cut unnecessary costs on inpatient admissions and readmissions as they move to a more ambulatory based presence.  However if they don't see the self interest will patients and communities demand change in quality and safety regardless of whether hospitals get paid?  And as they get educated, will they choose the safer hospital?  Not sure that the consumer of healthcare is in the driver-seat quite yet.

The cold truth

Okay so they are not death panels, but there is a big whopping barrier to healthcare, ie. good healthcare.  No its not the insurance guy keeping you away from the door.  Its the fact that you are without insurance, or on Medicaid and are a minority. 

So what is news about that...we have heard about the uninsured every day for the past two years of the healthcare debate and its getting kind of boring.  Well its not so boring if you are a tax payer.  As it turns out the emergency room fantasy that everyone has care if they are really sick, means that  the sickest folks are in the ER and  poor.  They require an ER when the rest of us get an annual mammogram to detect cancer.

I just completed the first phase of a study on cancer patients at an academic medical center and a county hospital.  Suffice it to say the the patient looks very different in the oncology department at the academic medical center than at the county hospital.  The AMC patient is more frequently insured and white and likely to be at any stage of a cancer.  The County patient is uninsured, minority and 50% likely to be end stage cancer. 

Who of these patients make it to their appointments to insure a chance of survival.  You guessed it the AMC patient has a statistical advantage that they will make their appointments.  But the interesting thing is if the AMC patient is not white or insured,  their likelihood of making it to their treatment drops significantly.

So why am I sharing this observation?  Because the system as currently structured is too difficult to access early diagnosis and treatment if you are poor.  In addition, the system is too difficult and time consuming and expensive even if you are at the best places for care.  It takes a village and if you don't have one, your outcomes will be poor.

What has an impact on this equation.  So far it looks like patient navigation, or the staff who dedicate their time to overcome barriers to care for patients.  It seems to work.  It doesn't balance the disparity of being poor in this county but it lessens the load and statistically improves outcomes. Kudos to organizations like the American Cancer Society in Illinois for taking on Navigation as a priority.

So what does this mean for reform?  More resources in patients emotional and social support are going to bend the cost curve.  And even more importantly, targeted early intervention for high risk groups.  Annual screenings and check-ups for those that never thought it was in their price point may be the difference between costly treatments in the last 6 months and treatments that improve the quality of life.

Where is AARP when you need them?

We do not need protection from death panels, but we do need advocacy about hospice, rehab, home health and specialty clinics.  Physical therapy is one of the leading barriers to an Emergency Room admission.  Long term care as an independent outpatient is the key to admission avoidance. So why are we reining in medicare rehab and cutting back on hospice.  These are services that make geriatric living work...and work independently and without nursing homes and with ERs and without ICUs.  Let's rethink quality of life.  It isn't being attended to by a swashbuckling surgeon but being calmly led to independence by a PT!

Facing Facts

Its monday and I either don't have enough tools and beds to make everyone happy or I have too many beds and tools and I am worrying about census and nashing my teeth about how in the short run to make it work. I know that the community isn't served equally and there are quality gaps that I could fill but I dont' have the resources. So what do I do?


Good question. You might want to consider buying the specialty practices that are crying about medicare funding. Buy you know that you really need to invest in primary care. How do you manage the change? How do you move through the transition in a meaningful way that doesn't bankrupt the house. Resist and yet move fast! How is that the strategy? How do you build the ambulatory care and let the specialty, the breadwinner, work its way through your fog? How do you extend your productivity in your least ROI guys and shrink the productivity in the most ROI guys? You just do. You figure out the balance and you slowly move in that direction and you bring folks along and you drop certain folks that don't meet standards along the way
This is tough work and don't do it alone. It requires a steel spine and a couple friends to get through it!

But the good news is they are predicting that the Medicare trust fund will be solvent for 20 more years...but only if you do the work that needs to be done!

Why can't patients schedule their visits themselves....

I expect that I can schedule every appointment by computer/email access. Is that my reality? Unfortunatley not.  I can schedule my car, my kids, my travel, my hair but not my primary care visit, my derm checkup, my endoscopy (okay maybe I should check in first with my GI).  I dial one number and repeat a couple numbers for my perscriptions, I register on line for every move I make in terms of restaurants and hotels and rental cars etc...so why can't I just schedule myself for an appointment without having to talk to two clerks and an electronic dialer to get an appointment.  Why can't I see the schedule options and do my mammogram and bone scan and blood test on the same day.  Why can't my annual visit for a skin scan and gyne appointment and primary care checkup all follow one another so I can get it done in the one day I take off.  Am I really unreasonable or is it possible that I can have some control over my schedule. 

Do we need a navigator for all our visits or do we need a system that allows visits to be scheduled in a way that we might make them.  Okay, if I need radiation therapy, they can still dictate the schedule (or at least for the first week!).

Time to think outside the box

Maybe I am awaking to a whole new planet out there.  When my daughter stepped off  the plane from Rwanda yesterday I realized that I too mentally went with her, tracking all things African over the last several weeks.  A place that I never thought I would step foot in, all of a sudden had a tremendous appeal.  I think that we in America are so used to tooting our own horn and adoring all things Western that we often fail to look outside our borders for solutions.  The world may be becoming more global but in our thinking about our own problems, we seem to be more inward thinking and often stuck.  We are feeding on ourselves instead of growing new ideas.

So what does any of that rambling have to do with Healthcare.  Check out this months Health Affairs for models of what works and what doesn't in other nations not just in Europe but in Africa as well.  The focus on primary care and prevention worldwide has some lessons for us.

Are we questioning our medical education system adequately? Look at the article on nurse anesthetist quality and the article on international graduates quality.  Our system is costly and slow and culturally difficult to change.  What if as in Spain, where I met young medical students who started their training Freshman year - not in premed but in 5 year medical school?  What if that model worked for primary care practitioners?  That might save the average primary care physician about $200,000 in tuition costs and begin their productive years as a new physician 3-4 years earlier.  The pressure on starting salaries and the attractiveness of primary care may be positively affected.  Read also about Spain's impact on health outcomes and the cost of their system.

Just thinking.....