hospital impact

by Christopher Cornue

Allow me to be bold and perhaps even controversial for a few moments (er, paragraphs), please. During a recent collaborative visit with some healthcare organizations in England this month (of which I'll be writing future postings in the next several weeks), I was hit by a revelation during one of my presentations. I was talking about some of the innovative strategies for total access in some of our states ... specifically, Massachusetts, Illinois, California and Oregon and thought about the unique opportunity that each state has in the US. Also, each state focuses on specific metrics (as part of a state-run group, Joint Commission or other national body). As most folks know, each of these states (and others) have developed different versions of plans to ensure there is access to healthcare for kids, women, or everyone, depending upon the respective state. It was then that I realized the United States is a huge laboratory for health care reform ... with 50 separate labs working on solutions to health care. This is exciting!

So, what if we take this to the next level (here comes the controversial bit, and I admit I don't know all the dynamics regarding the plausibility of what I'm suggesting - so don't kill me!). What if the Federal Government were to identify a block of funding for each state... and each state would be overall responsible for the delivery of healthcare in that state with: 1) everyone having access to healthcare; 2) quality metrics are established and trended; 3) patient's satisfaction with their care is tracked, trended, addressed; and 4) poor performers (hospitals, clinics, physicians, etc.) are improved. Each state can do something different, depending upon their unique challenges, population, resources, etc. -- but they would have the ability to create programs providing healthcare to their respective groups.

I know there are other options too (i.e., federal funding could be provided to each state to develop a program that could then be potentially rolled out nationally, etc.), and that's the exciting part - that there are 50 test tubes for what could end up being a solution to our healthcare issues nationally. So, is this "out there," are there efforts like this already in place, etc.? OK, I'm finished - thanks for allowing the moment of boldness!

by Tony Chen

Okay, this post has nothing to do with retail clinics, except that like these clinics, I'm purposely only offering limited services on a limited scope. Okay, I apologize for the weak analogy. Anyway, here's a few quick links on what's happening in the healthcare blogosphere:

- The Health Care Blog: An insider look at Google Health

- Health Affairs: Kaiser has started a blog watch

- The World Health Care Blog: Privacy 2.0

- Foresight.org: Nanotech could revolutionize diagnostics with nano-sized barcodes.

- FierceHealthcare: NEJM's study on social network's impact on health decisions

- Forbes: Stem Cells Get Real

- Health Management Rx: Why I Believe in Consumer-Centric Care, Part II (may be the longest blog post I've ever seen, but still worth the read)

- Dr. Wes: Criticisms of "Consumer-Driven Healthcare"

- USAToday: America's Fittest Cities

- FierceHealthcare: Consumer Reports to rate hospitals

and finally, the new EMR that will rock your world. Brilliant.

by Tony Chen

This past week, I was at the Front End of Innovation Conference in Boston. Overall, it was a great time to reflect on my own mindset about how to bring innovation to hospitals & healthcare.

Here are a few things & quotes I'm still mulling over:

On Being Customer-Focused
- A.G. Lafley (P&G CEO) had a ton of great insight. When asked about how P&G became so customer-centric, he recalled his first days on the job as CEO. "We were all so busy every day, so much so that our heads were in our phones/computers and our behinds were facing our customers." First thing he did was to get people out of their offices and into customer's lives and watch them.
- Google does this as well. One "problem" they deal with is that they work pretty hard, have a great campus that almost allows employees not to leave. Employees start living in a "google bubble" and "googlers are not necessarily representative of the general population." Google continuously sends teams out to watch people do searches and use their products in their "natural" environments.

On Humans
- I know this sounds cliche or stupid, but we're human. And humans are emotional and experiential. The most beloved products/services in the world just happen to treat us that way.
- Apple isn't selling a high-tech device, Apple is selling a human experience
- A.G. Lafley: "we have to understand what customers can't articulate." Customers might be able to express what they dislike, but they won't necessarily be able to tell you why or how to fix it.
- Peter Guber (Mandalay) - storytelling has been the key to his success, and the key to the success of just about everyone he knows (in entertainment or not). When you can tell a good story (about yourself, your product, your cause, your goal), it resonates with people emotionally and memorably. Good storytelling is not informational, it's emotional - it engages the heart and the mind.

On the Future
- Ray Kurzweil (Ridiculously accurate futurist on all things tech and IT) believes in the theory of the "law of the accelerating returns." The reality of innovation and of human history is that things don't progress linearly, things progress exponentially. That's because every new innovation we come up with accelerates the next innovation. Just think about "Moore's Law" - a "doubling every two years." Check out his work here and here
- Exponential growth and linear growth are hard to distinguish in the early years (because the numbers are so small). But the turning point (the bend on the hockey stick) is hitting us now in the areas such as solar energy (within 5 years, solar energy will be cheaper than fossil-fuel energy) and reverse engineering the human brain (15 years, we'll have ridiculously real AI)
- Devices won't be laptops or PDAs - devices will be in our clothes, in our heads, in our bodies. Sound crazy? There are 50 studies being done right now in animals on implantable devices. One has cured diabetes in rats. One is an in-blood device that finds and destroys cancer cells.
- We can learn about innovation from the one obvious place no one really looks: nature. Why? Because every single organism has been an innovator for billions of years in order to survive (99% of all species are extinct) We can take advantage of those billions of years of "market testing" by reverse engineering nature. Check out some examples here.

As I said, I'm still mulling over what this all means. In general, I think I tend to overestimate what innovation will bring in the short-term, but greatly underestimate what innovation will bring in the long-term. New innovations are accelerating and will vastly change the landscape of healthcare as we know it. Hospitals that go out on a limb and catch the wave will have to take big risks but also stand to reap tremendous rewards.

by Christopher Cornue

I've written in this space before about a national collaborative, funded by the Robert Wood Johnson Foundation (RWJF), called Expecting Success: Excellence in Cardiac Care. This was a 29-month collaborative project, led by the George Washington University and comprised of 10 hospitals from varying communities in the United States. Detailed information is available at the website and further tools developed during this process will be available at a new website in June (I'll post an update when that becomes available). Briefly, though, I want to call out some significant successes from this project that "formally" concluded a few weeks ago and were shared at a national meeting in Washington, D.C on 8-9 May 2008.

* Each hospital implemented a consistent way of collecting Race, Ethnicity and Language, based upon OMB classifications - this is expected to become a Joint Commission requirement in 2009. These data allow hospitals to identify potential disparities, and then implement changes to address any that may exist;
* Through the project, 61 statistically significant changes in quality occurred (58 of which were improvements; while 3 were declines);
* Evidence-based "Measures of Ideal Care" for AMI improved significantly across the hospitals since the project began in Q4 CY2005 through Q4 CY 2007: mediancompliance increased from mid-70% to upper 80%; additionally, the spread of compliance across hospitals (which in the beginning was a large gap between approx. 17% to 93% to a much smaller gap of approx. 77% to 100%);
* The gap for "Measures of Ideal Care" for Heart Failure were even wider than AMI when the project began (approx. 5% to 88% compliance in Q4 CY 2005) and ended with a narrower gap of approx. 59% to 98%);
* Some hospitals demonstrated a significant reduction in the gap of care provided by race and ethnicity - with one example focusing on percentage of AMI patients receiving ACE/ARB for LVSD where in early 2006, whites received ACE/ARB 90% of the time while blacks received it approximately 76% of the time. By the end of the project, the gap had closed to such a significant degree that both received ACE/ARB 100% of the time.

There were many other noteworthy examples demonstrating the significant improvements. Suffice to say, quality has improved significantly at these 10 hospitals over the past 29 months, with the gap in race and ethnicity closing. While more specific info about next steps will be shared in June and July this year, RWJF plans to implement this project on a broader scale nationally, using lessons learned from these 10 collaborative hospitals. Their focus will be on dozens of communities across the country in an effort to spread the successes and ultimately improve the quality of care in cardiac care, while reducing disparities where they may exist. More detail to come ...

by Tony Chen

Google Health launched today. Check it out here

As you can see,, there's 4 calls to action:
- I can add info to my profile (stuff like conditions, medications, allergies, procedures)
- I can import my medical record into Google Health (right now, the only options for this are info from Cleveland Clinic, Beth Israel Deaconess, Walgreens, CVS, Quest, and a few others - so I'm out of luck here)
- I can explore online health services. The first 3 services listed? Cleveland Clinic's eConsult service, ePillBox.info (free med mgmt tool), and AHA's heart attack risk calculator.
- I can look for physicians using a drop-down specialty box and typing in key words/locations.

There has been a lot of hype about how Google and Microsoft will "change healthcare" because of their new services, so today we can get a sense for whether they're going to live up to all the hype.

What I liked
- I give Google high marks for what they do best - taking complex information architecture and making it simple and easy to navigate. The navigation for the site was very intuitive for me. I added to my profile the items I wanted pretty easily (I wish I can see how the import works - if anyone did this, please comment!). I searched for my primary care physician and clicked "add to my medical contacts", and boom, his info was stored there for me for future reference. It's pretty easy to add immunizations/procedures/meds - I could pick it from the list. Or I could start typing in the open text box, and the more letters I type, the likely field appear (just like we do now with email addresses)
- I liked the fact that there's a drug interaction area. As I added meds, it showed exactly which interactions to watch out for.
- I liked being able to create a new profile (which I did for my 2-year-old).

What I didn't like
- They still need to fix the "find a doctor" function. I typed in some docs I knew and for some reason, their practice partner's names come up, not theirs. So, it was pretty confusing.
- It's still unclear how to "use" the record besides just having it all in one place. I've heard that patients will be able to choose what part of the record to share and with you, but didn't see that in this release. There's no option to download the data, either. What else can I do with it?
- I wish they added some sort of HRA & fitness/wellness area. Now that would drive usage - if I could traffic my weight, workouts, bp, whatever. After all, it is launched as Google Health, not Google Health Care. Nonetheless, maybe they've decided to give that piece of the pie to others.

Where hospitals have opportunities
- Tech-savvy hospitals should be able to start looking at linking their EMR's into Google Health. Of course, there's some tension with this as many hospitals are trying to drive stickiness/traffic to their EMR portals. This would stand to compete with that. Why would a patient log into their hospital's EMR system when Google's system is probably easier to use and more visually appealing. On the other hand, hospitals that do have the link the Google Health provide their patients will this added benefit. Maybe patients will increasingly ask their physicians who will increasingly ask their administrators?
- Tech-savvy hospitals and others can try to have their online services added to Google's list of online services. This is essentially another channel to drive traffic/utilization.
- Hospitals who are savvy in the ways of 2.0 will have their physicians appear higher in search results. Yup, this is yet another way to search for physicians, but honestly, I doubt people will use this tool to make physician decisions. More so, they'll go onto HealthGrades or other Physician rating sites. The "Find a Doctor" option on Google is more so that we can automatically add our physician's info into our profile quickly.

Here are a few other notable mentions of Google Health:
Blogscoped
news.com
GeekDoctor (CIO BIDMC)
TechCrunch
ScienceRoll
Healthcare IT Blog

More on this soon, as they unveil more details in today's press conference.

by Tony Chen

I'll be at PDMA's "Front End of Innovation" Conference in Boston next week. If anyone is around and up for drinks, let me know.

Last time I checked, I couldn't find any other hospital members of the PDMA (Product Development and Management Association). Think of them as the ACHE for innovation & product development people. As I interact with this group, I'm definitely stretched by their progressive thinking about how to bring innovation into any culture/organization (apparently, the Russians did a lot of innovation theory work back in the day that are still being utilized widely today).

What can hospitals learn from the likes of Dow, Staples, Google, Starbucks, IBM, Kraft? I'll let you know.

by Nick Jacobs

What’s this generation coming to? It started some years ago with new rules for residents. They no longer were permitted to be worked 80+ hours per week as part of their residency. In fact, many residents actually keep time sheets and then tell their MD/Professors when their work week is complete. It wasn’t that many generations ago that student nurses and residents were the only people working the night shift in even prestigious medical centers.

What else is happening? New generations of physicians are actually seeking to attempt to balance their work time with their free time. A front page article in the Wall Street Journal by Goldstein reported that U.S. medicine is in the middle of a cultural revolution. According to the article, young physicians are beginning to challenge the fact that they must be available to treat patients around the clock. According to President Ronald Davis, M.D., “There has been a sea change in how young physicians today balance professional responsibilities and personal needs, compared to their colleagues from a few decades ago . . .Physicians who manage their own stress and feel happy with their own daily circumstances are probably better physicians.”

As a hospital CEO in Pennsylvania, we are seeing “The Perfect Storm,” as catastrophic liability insurance is no longer available to our physicians. Ninety plus percent of our State’s finishing residents are leaving. The newer physicians who are considering staying in State are actually demanding free time, comprehensive call coverage, and weeks of vacation and continuing medical education time. Quality of life issues?

So, as 78 million Baby Boomers head toward the proverbial wall, we not only have a significant shortage of gerontologists and other sub specialists, we are also faced with young, smart physicians who actually want a life. Hold onto your hats.

by Tony Chen

I have an idea that I wanted to share with you - please give me your honest opinion (i.e. you can tell me if I'm crazy!). I would love to find others to collaborate with on this. So, if you're interested, contact me directly (tony at hospitalimpact dot org) or comment below. Obviously, the idea is still very rough, but hopefully you'll see where I'm heading. And hopefully, we can refine it together.

What do you think about a new a philanthropic/VC hybrid that invests in preventive health projects that yield at least 338% ROI? (thus the name "The 338 Foundation.")

I'm going on 2 key assumptions:
1. Prevention is one of the biggest opportunities in healthcare. We don't have a healthcare crisis as much as we have a health crisis. We need to pour out a lot more creativity and resources for prevention/healthy living.

2. The biggest obstacle around prevention is a lack of (or misaligned) incentives. No one wants to invest the real money for what's truly best for the patient because these potential investors (whether they be hospitals, insurance companies, pharma, or other companies) make the investment, and others would get the benefit.

For example, a hospital may choose not to hire a chronic disease mid-level practitioner because the "cost savings" it generates essentially goes to the insurance company. Maybe the hospital saves some real costs from reduced ER visits, but not enough to pay for itself. With so many pressures on margin, I can't blame them for that decision. Insurance companies are investing in some disease management 2.0 items, but I doubt they will ever really invest because their members stay with them for only a few years (I've heard 2.5 years?). So any investment they make into keeping the patient healthy is most likely benefiting their competitor (i.e. who ever happens to be their member's insurance company 5 years from now)

It's the classic case of no one wanting to do what's "right" because they pay 100% of the costs while reaping only a fraction of the benefit. So this idea would turn that notion on its head by getting all interested parties to pool their resources together into initiatives that collectively will pay off for all of them.

How I could see this playing out:
- Some smart, collaborative healthcare people could solicit and collect all potential ideas/projects/research and rank them by ROI & approximate benefit to each industry.
- We would welcome individual and corporate donors to the foundation.
- We could do a targeted pilot (i.e. partner with the City of Chicago - i.e. trying to get Chicago to be the "healthiest city in the U.S. by 2015")
- Solicit proposals/applications from organizations who can most effectively implement these projects.
- Fund based on potential ROI and effectiveness of organization's implementation proposal.

So, what's the significance of 338? I'll leave that as a riddle for you. It has to with an important year coming up in our lifetime.

(one side note: One of the ideas I would love to see funded is a savvy viral advertising campaign that changes how people think about their lifestyle habits, like how http://www.thetruth.com/ reduced teenage smoking)

Imagine investing in a fund that yields $3.38 savings/benefit for our country for every $1 we put in.

Please comment/brainstorm with me! Is this crazy or what?

by Nick Jacobs

My first health care administration job began in 1988. It was a warm September morning when we met around a large table to examine the financial report of the hospital. The CFO reported out the income from operations, and, although I was new to this particular field, it struck me that all we were looking at was the inpatient report. When I asked where the outpatient information was, he replied, "Oh, we don't have any way of capturing that information." To which I asked, "Isn't that at least 50% of our business?" The answer of course was positive. It was at that very moment that the history of health care management came crashing in on me. Not unlike a University, if the money didn't balance, you just raised the tuition, or, in our case, the costs. Many refer to that time as the "good ole days."

This week, the Wall Street Journal had a blockbuster article that should have been entitled, "Dah." It was about the new wave in hospitals to collect cash upon registration for deductible insurance costs. It was entitled Hospitals Demand Cash Upfront from Patients. It's a revolutionary new idea in hospital billing where hospitals actually are making medical care contingent upon up front payments. At least that is how the WSJ depicted it.

In my world, it does not seem quite that drastic. Hospitals are just trying to collect those payments that seem sometimes rarely to be collectible. We do not deny access based on their ability to pay.

Clearly, bad debt is becoming more of a problem for us each and every day, and this is just one very late attempt to function like a business.

We need help, and, not unlike physician offices, why is it wrong to ask for co-payments as the patient enters? Your comments are welcome.