Synthetic Biology and the future

I found the following video on Paul Levy's "Not Running a Hospital" blog. Engineering living beings is certainly exciting and filled with sober questions about what may be possible. I wonder about the applicability of our patent systems. I suppose that our legal scholars and others have already concluded that life (to a point) can be owned by those who "create" it.

Competition and costs of health care

Here is CNN special report by Professor Amitai Etzioni explaining why strategies to control rising healthcare spending are not likely to be constrained by plans based on competition.

http://www.cnn.com/2011/12/27/opinion/etzioni-health-care-competition/index.html?hpt=hp_c2

For all the reasons he cites, patients are not in a position to constrain healthcare spending. And even if they/we could, we would likely engage in cutting back on preventive care, driving up costs in the long term. It seems to me that every good policy initiative intended to save money has been turned in a way that contributes to continuing increases in costs. The reality is a very complex network of incentives. Whatever new policy is initiated, people are going to find ways to exploit the new system in unintended ways. Here in Albany, Georgia our largest hospital system has just acquired the other local hospital despite concerns by the Department of Justice and others that the acquisition will reduce competition and lead to higher costs. I suppose one approach to creating an Accountable Care Organization is to own all the necessary parts of one. I can imagine that the recent Patient Protection and Affirdable Care Act may encourage hospital system administrators to buy up their competitors to avoid the legal and other challenges of participating in the creation of an ACO.

Markets and governance

I am concerned by potentially revolutionary movements on both the right and the left side of the political spectrum in the United States. I am concerned that our system is broken and can longer able to generate rational solutions. Healthcare reform cannot be successful if transformation is impossible because of constrained resources and political failures. Those people who can cope with complexity are disadvantaged by our political system and are unlikely to win political office. I fear the resulting polarization and the social consequences.

Translational research and wireless technologies

Eric Topol, Director of the Scripps Translational Science Institute at TEDMED 2009 offered a compelling vision of the convergence of medical practice and mobile technologies. Dr. Ricardo Azziz, President of Georgia Health Sciences University and CEO of Georgia Health Sciences Health System, recently shared his vision of clinical and translational research. These are surely exciting times as we may be approaching some kind of medical-technological singularity beyond which the future will become difficult to predict.

http://azziz.georgiahealth.edu/archives/367

The iPatient and the real patient

In this TED video physician Abraham Verghese of Stanford University makes his case for the importance of ritual in patient care, saying that technology can become the focus of a physician's attention at the expense of the need of the patient for a human relationship with his or her medical caregiver. He cites the need for a listening to the patient and giving a through physician examination in person as a way of gaining the confidence of the patient in a way that a scans and lab tests cannot. It seems to me that the challenge is to retain the ritual while including the technology. We live in a world in which friendship is increasingly being understood in context of social media rather than in the context of physical proximity and time spent together. Cyberspace is amazing and allows for social connections that would not otherwise be possible. Medicine is very largely about data, information and knowledge. It is also about caring for the actual person.

http://cnn.com/video/?/video/living/2011/10/01/ted-abraham-verghese.ted

High technology prosthetic devices

This video is about the use of technology to improve prosthetic devices and to potentially modify and extend abilities of human bodies. Where does the right to healthcare end in the United States? Is it rationing to provide these devices to some people and deny them to others? Is the "line" the point at which the device provides enhancement beyond natural abilities, contrasted with "merely" restoring a lost functionality?

Lead the cause of poverty cycles?

While doing homework for my course in Environmental Health at Georgia Health Sciences University yesterday I found this video of Congressional testimony by Dr. Herbert Needleman dated 1991. I did not realize how dangerous old lead paint is to children and the neurological damage and learning disabilities it can cause. Given that children in poor families must often live and attend school in old structures is there reason to wonder why we as a society continue to struggle to break the cycles of multigenerational poverty?

Remembering September 11, 2001

Like most people I remember some of the details of the morning of September 11, 2001. I was preparing to teach a class at a university in Southeast Kansas that morning. One sad truth is that people are still suffering and dying as a consequence of the events of that day. To conclude that the high rates of cancers among those who responded to that event cannot be scientifically linked to exposures to toxic dusts seems disingenuous to me. If our nation cannot afford to provide the first responders healthcare treatments for their present conditions then I wish some official would simply say so. I remember walking to lunch at Taco Bell through the fairly deep snow that morning. There were long lines of cars at the gas station next to the railroad track, waiting to be filled with gasoline. The sky the next day was the most beautiful blue sky that I have ever seen in sixty years. To think that I was stepping through snow in September in Southeast Kansas seems odd only ten years later. The fact that the grounding of commercial aircraft produced such a dramatic difference in the appearance of the sky is remarkable. I remember as a small child in the 1950s that I could see thousands of stars almost every night. Now, ask a young person if he or she has even once seen the North Star, the big dipper and the little dipper. Their only dippers are likely to be dairy treats. As I remember that fateful day I do so in the context of the evidence that there are things even more frightening than acts of terrorism affecting the health of earth's living beings.

The value of connections

Tim Berners-Lee changed the world, recently. He is credited by Time Magazine and others as the inventer of the World Wide Web. His vision and passion are evident in the TED presentation shown below. His vision is not limited to an innovative way for electronic devices to be connected. His vision extends to the connectivity of minds and the many possible transformations of the world. It often takes years for the knowledge produced by medical research to become applied in actual patient care. We are a society obsessed with the possession, protection and ownership of data, information and knowledge. It is a rare person who puts contribution before self enrichment. The coming revolutions in healthcare will largely be based upon the values of people like Tim Berners-Lee.

Hospitals should not fly on autopilot alone

The CNN report below by Brian Todd and Dugald McConnell is disturbing evidence that professionals can become too dependent upon computer systems. As computers become smarter humans are becoming more entirely dependent upon them. That is scary. One of the most fundamental aspects of flying is knowledge that when a plane is near a stall condition you put the nose down (assuming you have some altitude to work with). For a copilot not to have converted that from knowledge into instict is a serious issue. It is true that when one flies "by the seat of the pants" bad things can happen. But to substitute faith in computer systems for tacit knowledge is not good either.

Medical settings, of course, are highly automated these days and many new employees are members of "generation net," meaning that they grew up with digital skills (Tapscott, 2008). There is a limit to the degree to which automation can substitute for human knowledge and skills. To think that the transcription of audio tapes by physicians into medical records might be accomplished using voice recognition software is, in my opinion, outrageous at this time. Humans should oversee what computer systems are being programmed to do. The answer is not just more intuitive computer interfaces. Computer systems today are intentionally being designed to minimize the need for human working memory. The answer is humans who although they grew up digital still have real tacit knowledge. We may already be beyond the point of no return.

Tapscott, D. (2008) Grown Up Digital: How the Net Generation is Changing Your World.
New York: McGraw-Hill.



http://www.cnn.com/2011/TRAVEL/09/01/airlines.autopilot/index.html?hpt=hp_bn12

Most connect hospital list uses HIMSS Analytics data

In this video John P. Hoyt, Executive Vice President of HIMSS Organizational Services explains the organization's EMR Adoption Model. Additional information is available at the following URL.

http://www.himssanalytics.org.

With courage and grace

This statement by Coach Pat Summitt helps us realize that a diagnosis of Alzheimer's is something that people can accept (and accept in others) and not a reason for withdrawal or denial. It takes courage and public transparency to make a statement like this statement. It takes understanding for an organization like a major university to to stand by someone willing to face up to a difficult diagnosis.

Big Data and Digital Epidemiology

In the following TEDMED video Nathan Wolfe, director of the Global Viral Forecasting Initiative goes beyond talking about the role of viruses in human history to suggest the implications of connectedness and information exchange.

Cause for notice

What will become of the nation's healthcare policies and institutions if American moves dramatically toward becoming a theocracy in 2012?

http://caffertyfile.blogs.cnn.com/2011/08/17/17612/?iref=obnetwork

The price of diplomacy

There is an article on the CNN site today reporting evidence that dogs have an ability to detect cancer by their sense of smell.

http://thechart.blogs.cnn.com/2011/08/17/growing-body-of-research-says-dogs-really-can-smell-cancer/?hpt=hp_bn6

There is a link in the CNN article to the following blog post.

http://www.cancer.org/AboutUs/DrLensBlog/post/2006/01/11/Dogs-And-The-Early-Detection-of-Cancer.aspx

Several readers have posted comments saying that they can also smell cancer on others, even in public places. One comments that when she smells cancer on a stranger she does not say anything because it would be socially awkward to suggest that the stranger see a physician. What do physicians who are dermatologists do when they see a mole on person that they they know from professional experience should be removed and sent to a lab for testing? My guess is they say nothing because to do so would probably violate some professional norm or law regarding self referral. We need diplomatic ways to signal concern to one another (including people we don't know) without creating unnecessary alarm or offense. It seems to me that the price of silent diplomacy is high.

Health Literacy and Environmental Health Awareness

I am preparing to take two online courses this fall offered by Georgia Health Sciences University. One course is in environmental health. I plan to write a paper regarding health literacy and environmental awareness. An article by D. W. Baker (2006) addresses the meaning of health literacy in terms of the reading and writing that constituted literacy when I was growing up. But literacy today extends the use to use computers and mobile devices. There appears to be a huge and growing literature on mHealth - regarding things like health-related applications running on tablets and smart phones.

http://mashable.com/2011/08/09/kids-tech-developmental-health/

I have not yet concluded what to think about the pros and cons of children growing up in an electronically connected world. As a person who sometimes finds that eye contact interferes with my ability to think while speaking, the article above caught my eye. It is apparent to me that technology is changing humanity in parts of the world in which electronic devices are everywhere. This video of a child's first experience with an iPad is interesting. What are the implications for her future health literacy?



Reference

Baker, D. W. (2006). The meaning and the measure of health literacy. Journal of General Internal Medicine: Official Journal of the Society for Research and Education in Primary Care Internal Medicine, 21(8), 878-883.

House vote on the debt ceiling legislation - August 1, 2011

I watched the members of the U.S. House of Representatives vote on the debt ceiling legislation this evening and am reflecting now on the meaning of it. The scholarly explanation is that as a complex adaptive system our political system is presently stuck in a dysfunctional attractor. Assuming the U.S. Senate votes for the same language tomorrow and the President signs, I think they will have essentially kicked the can down the road a piece. I think our nation will soon lose its AAA credit rating and that all Americans will experience the equivalent of a substantial tax increase - not just the few who were saved from a return to their obligations during President Clinton's presidency. In my opinion, this bill will have more adverse financial consequences for "corporate jet owners" than a more responsible bill would have had. A more responsible bill would have prevented a probable loss in the nation's credit ratings that I think will hit every American -- not just those who are best able to buy their access to political power. I doubt that the stock markets of the world will be pleased by this legislation. My only moment of celebration this evening was the return of Representative Gabrielle Giffords. To me, she is more than a member of Congress. She is a living symbol of a great nation and of courage and survival.

Regarding the specific subject of this blog, a CNN announcer this evening made reference to future cuts affecting healthcare providers but not patients. Whatever affects providers is going to affect patients directly or indirectly.

The new face of healthcare competition?

Here is an interesting news story about one hospital in Albany, Georgia.

http://www.walb.com/story/15159417/phoebe-putney-announces-price-cuts

The present debt ceiling crisis

Like most people I am distressed by the present crisis regarding the nation's debt ceiling. Our nation must turn the corner and it is, of course, a difficult corner to turn.

Four thoughts cross my mind when trying to make sense of the present state of things. One is former President Clinton's unusual response to a question asked by senior White House reporter Sarah McClendon years ago in the context of possible UFO disclosure. He is reported to have said, "Sarah, there's a government inside the government, and I don't control it." In this context, the point is that there are probably very large hidden budgets sapping the resources of the federal government of the United States for purposes known to very few.

My second thought is that our nation's present situation is in part a result of the fact that because it has limited powers our national government is left to try to implement policies by creating incentive systems that produce patterns of behaviors. There are at least two problems with this. One, carrots are expensive! Two, incentive systems almost always produce unintended behaviors that undermine the intended results.

Third, when government pays for something with the best of intentions it is likely that more of whatever is intended to be addressed becomes manifest. We assume that the solution addresses the need when in fact the solution may drive up the need.

Finally, major breakthroughs in various kinds of medical research would be disruptive to both existing research communities and existing specialist medical providers. I want to believe that all researchers and providers want what is best for patients and for the nation than want to sustain a status quo in which they have become well adapted.

List of resources regarding Comparative Effectiveness Research

I have reason to gather resources regarding comparative effectiveness research (CER) related to my being a student in the Master of Public Health Informatics program at Georgia Health Sciences University. I think I will develop a list of resources here and hope that readers may add to the list by making comments to the post.

"Health Care Refort and the Need for Comparative-Effectiveness Research
The New England Journal of Medicine, January 6, 2010
http://healthpolicyandreform.nejm.org/?p=2719

"Giving Teeth to Comparative-Effectiveness Research - The Oregon Experience
The New England Journal of Medicine, February 3, 2010
http://healthpolicyandreform.nejm.org/?p=2936

The Genomic Revolution

In this video which was part of TEDMED 2010 Gregory Lucier, Chief Executive Officer of Life Technologies anticipates the coming of the genomic revolution within the next two years and the possible constraint on its arrival.



He envisions a day coming soon when cancer patients will receive prescriptions for custom combination of drugs based on what physicians learn by use of the genomes of the patient and of the tumor. In his opinion, the technology will be "there" and the likely constraint on the arrival of the revolution will be FDA approval requirements which he says need to be modified.

I am thinking now of the prospect of applying comparative effectiveness research to the use of genomics in medicine. Assuming the "revolution" happens within two to five years, there will be huge implications for clinical pathways. I don't pretend to know how this will work out. Will genomics possibly drive population-based preventive care? Will there be cures for cancer? Will many kinds of cancer become manageable chronic conditions and no longer life-threatening? How might organizations that derive large revenues from traditional cancer treatments adopt to dramatic changes in the treatment of people with cancer? What are the implications of genomic medicine on the costs of care for individuals and for populations? We all wish for cures for cancer and other serious diseases and conditions. The powers that be will assess the potentials of genomics and will shape the revolution and its results from interests defined by existing paradigms.

Getting the right mix of patients

Paul Levy recently included his BBC video clip on his blog, "Not Running a Hospital."






In the United States, of course, it would be the hospital administrators who would be more concerned about an empty hospital rather than a government official. The challenge going forward in the U.S. is for each hospital to have the right mix of patients for whom revenue comes from services provided and patients for whom revenue is from capitation. The costly facilities will have to be there for those patients for whom the hospital is at financial risk (the capitation groups). But there must also be enough patients for whom the hospital has a financial incentive to actually use the costly facilities and equipment. In such a situation, some patients are more likely to be admitted to the hospital than others based upon whether they are insured through capitation or through a fee-for-service group contract. At first glance, it would seem that it is the patients in capitation plans that are at the risk of being shorted. But if the revenue needs of the hospital lead to unnecessary utilization of inpatient services for others, they may experience unnecessary medical risks.

It would be nice if there was an easy alignment of population-based care, patient-centered care, and the effective financial support of hospitals. But neither the market nor a centralized command system (as represented in the BBC video clip) will produce or sustain such an alignment. Whatever comparative effectiveness research indicates is the best clinical pathway for a particular patient, the decisions made about his or her course of treatment will be shaped in part by how providers are compensated for that patient's care.

Challenges beyond Jeopardy

IBM has an amazing history. It built its corporate culture and initial wealth building and selling mainframe computers to large bureaucratic organizations. IBM tried to make the adjustment to networks of microcomputers in the 1980s and had to shatter and reinvent its corporate culture in the process. IBM invested in Second Life apparently thinking that the next great thing might be in virtual worlds. Now it seems to be betting the store on its ability to move from the information business to the knowledge business and in so doing transform many industries including healthcare.

Let's assume for the moment that a comprehensive knowledge base of evidence-based clinical pathways has been build and that some very advanced computer like Watson has the software inference engine to make important decisions about patient care based upon the input it has instructed human medical providers to enter. And let's further assume that organizational changes have been implented in the United States that have resulted in a very high degree of medical conformance in implementing "Dr. Watson's" instructions. Would this necessarily be a good thing? What would be some of the consequences?

A Star Trek fan, I remember the episode titled Spock's Brain first broadcast September 20, 1968. Dr. McCoy is tasked with the responsibility to put Mr. Spock's stolen brain (being used to run the public works infrastructure of a city on some other planet) back in place and reconnect it to his nervous system. But the knowledge of how to do that, once known, has been lost. McCoy puts on a device known as, "the teacher" that allows him to recapture the knowledge needed to perform the work.

I cite the episode of Star Trek to suggest the if we did have a computer system like IBM's Watson loaded with evidence-based medical pathways we would in the short term advance medical knowledge but in the long run we would lose grasp of medical knowledge. Watson, as amazing as it is, does not have knowledge. It only processes patterns. The GPS unit that I sometimes use while driving seems to have a capacity for thought and I sometimes project into its voice the evidence of judgment. I sometimes image that its spoken word, "recalculating" is really its saying, "You dummy, I told you to turn back there!"

There is the knowledge that exists in individual human minds, and there is social knowledge that exists in social networks. While computers can facilitate human knowledge (both individual and social) they do not have knowledge and are not likely to gain that ability. My point is that as we become more dependent upon computer systems we risk losing "the old knowledge" that we will need to not begin to treat computers as if they have knowledge.

The risk resides not so much in the potentials of technology as in the capacity of humans to anthropomorphize computers and robots. Build an attractive robot (it does not even have to have human features) and put something like the inference engine of Watson behind it and people will begin to trust this entity that in fact has neither knowledge nor emotions. "Watson," in fact, understands nothing. Human care givers will become the interface between the technology and patients but will lack the ability to effectively judge decisions suggested (or made) by the technology. There will be no "teacher" device that one can put on to know what is represented in the computer system in forms that are less than knowledge. Computers are dumb but they have massive memories and incredibly fast processors. Computers can be networked together into massive arrays. Humans are smart but have tiny working memories, slow processing speeds and as of yet we have not created high bandwidth social networks. Clearly there is need to design more effective joint cognitive system (see book by Hollnagel and Woods) for medical and other purposes, while facing the prospect losing our knowledge of how computers are making decisions without knowledge.

Clinical Pathway Specification at what Grain?

This relates to Dr. George Lundbery's video editorial available in yesterday's blog post here. According to his explanation the right clinical pathway (regarding a specific condition in his example) depends upon the stability of the patient. Apparently physicians are continuing to follow evidence-based practice when the patient has not been stabilized but then are not shifting to the less costly equally effective evidence-based practice when the patient has become stable. So what is at issue is the grain of the specification of what is the best evidence-based practice. I imagine that if the less costly practice was to be followed on both stable and unstablized patients, physicians would more likely conform. As it is, their conformance requires an adjustment in practice during the course of the clinical pathway.

What I am thinking now is that if clinical pathways are written at a high grain (relatively few dimensions of criteria) conformance by physicians is likely to be high. But as additional dimensions are added to the criteria (such as stability of the patient) rates of conformance are likely to drop because conformity becomes more difficult. As the specificity of the pathways becomes higher conformity will become more and more labor intensive and cognitively demanding. This will clearly lead to automated systems and physicians will be asked to input a lot of data, surrendering judgment to the expert system software. It will become increasingly time consuming to document why the physician disagrees with the output of the system and physicians will feel a loss of autonomy as their role becomes more nearly that of highly credentialed technicians.

There is a differences between pay-for-performance and pay-for-conformity. Under pay-for-performance judgment remains within the physician's discretion. Financial rewards are based upon outcomes rather than processes. Under pay for comformity, most judgment shifts to the automated system. I am not advocating anything here. The grain of the specification of clinical pathways and the distinction between pay-for-performance and pay-for-compliance have many implications I hope to explore in future posts.

Comparative Effectiveness Research

Having recently been accepted into the MPH Informatics program at Georgia Health Sciences University I visited the campus recently to speak with a program administrator and a faculty member. We tentatively decided that my capstone research would relate to comparative effectiveness research (CER) and possibly to the modeling and simulation of clinical pathways in the context of CER. So it is likely that my posts here will become the evidence of my learning about CER.

In the following video editorial George Lundbery, MD, Editor-at-Large of MedPage today, (http://www.medpagetoday.com/) suggests that physicians may resist change in how they treat patients with particular conditions for reason of multiple motivations including money, collegial medical relationships and an aversion to simple remedies.

For what it may be worth, my initial impression is that physicians and others are likely to see evidence-based clinical pathways as a threat to professional autonomy. In the presence of a prescribed clinical pathway physicians may have to justify deviations from the pathway, which can be time consuming and annoying, especially when the physician has sound reasons for not following the evidence-based pathway in the cases of particular patients. If there were a compete set of clinical pathways it would only be by way of "deviance" that continued learning could happen. We are not at risk that through universal compliance with evidence-based pathwyas we will lose the opportunity to learn through variety of physicians' decisions.

As I anticipate my capstone research I hope to discover ways to model and simulate the financial and other implications of alternative clinical pathways in some identified clinical domain. I anticipate finding that no single pathway is optimal in light of every relevant value. I think too often references to the combination of population-based health care and patient-centered medical care are glossed to make it appear that both can be optimized at the same time. I think Dr. Lundbery's editorial suggests that it not as simple as understanding such trade-offs. There is the burden of precedent and comfort with existing practices and cultures that benefit multiple stakeholders. I am not sure his word, "courage" is quite the right word in this context, but perhaps it is.

Toward a Complex Adaptive Health Community

The "One-click Download" at this URL will display a paper titled, "The Wiki and the Blog: Toward a Complex Adaptive Intelligence Community" by D. Calvin Andrus of the Central Intelligence Agency. The paper was published in Studies in Intelligence, Volume 49, Number 3 in September of 2005.

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=755904

The essence of the paper is that Web 2.0 tools including wikis and blogs can be used in organizations as effective means of knowledge sharing. The author attempts to make ties to information theory and complexity theory to say that systems (organizations) can be designed to promote the emergence of knowledge from within rather than from above. As I teach courses in Public Administration I try to help my students understand the importance of "connecting the dots," as, for example, in case work. Because of their hierarchical structures bureaucratic organizations often do not facilitate the flow of information throughout and among agencies. Networks can facilitate information flow more effectively, but there is no assurance that information will flow where it is needed without a culture that encourages sharing and some means of shaping information flows. I liken this to hydrology and landscaping. Good landscaping usually does not have to depend upon sump pumps to control the flow of water. Good landscaping "helps" water find where it "need to be" rather than controlling it by force. In organizations there needs to be a means by which people can signal to others what information they need and what information they do not need. Information flows through social networks that are shaped by personal relations as well as defined roles.

Like the CIA and other intelligence organizations, healthcare organizations are information intensive. Decisions must often be made quickly by people who may not have immediate access to all the information available within the system. The flow of vital information is shaped by organizational cultures and by traditional professional roles. Patients are sometimes seen as passive recipients of care rather than as key information resources. In fact, success or failure is largely in the hands of patients who may or may not comply with care directives. Cost containment is also larely in the hands of patients.

I believe the key word in the title of the paper by Andrus is, "toward." Intelligence agencies do not yet always "connect the dots" quickly enough. For all the virtues of emergence, it is a slow path to design. Healthcare institutions are complex adaptive communities. To the degree what we can "landscape the cultures" in which healthcare services are provided we can improve the quality of care. There are multiple kinds of barriers to information flow in healthcare organizations. Design solutions are not exclusively structural or technological. People need to think before they click on the "send to all" button. We need to become more aware of the systemic consequences of how we share (or not share) information. We need to become more aware of how attitudes, professional roles, and other aspects of culture affect informtion flow and health outcomes.

Supercourse: Epidemiology, the Internet and Global Health

Here is the description of "Supercourse" from the home page at the following URL.

http://www.pitt.edu/~super1/

"Supercourse is a repository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 56000 scientists in 174 countries who are sharing for free a library of 4855 lectures in 31 languages. The Supercourse has been produced at the WHO Collaborating Center University of Pittsburgh, with core developers Ronald LaPorte, Ph.D., Faina Linkov, Ph.D., Mita Lovalekar, M.D., Ph.D. and Eugene Shubnikov M.D.. Please contact us at super1@pitt.edu"

First Reflections on the 2011 AUPHA Conference

I just returned from the AUPHA Conference in Charleston. Reflecting upon the sessions and the conversations I am struck by the strength of commitment to prepare graduate students to effectively manage the dramatic changes taking place in healthcare today. These women and men, living in the "publish or perish" world of higher education and the "politics" within universities, have real commitments to their students and to helping less-experienced scholars entering the field become effective teachers. There is a deep awareness that the quality of classroom teaching literally means the life or death of future patients and the success or failure of healthcare organizations.

Clarification of Care Pathways and related terms?

It is Saturday evening and I am trying to sort out in my mind a set of related concepts that appear to be near the heart of how ACOs will hopefully help reduce costs and improve outcomes. It appears that a number of terms (clinical pathways, care pathways, integrated care pathways and care maps) are all used more or less interchangably. If so, there appears to be a need to sort out these terms and to use them more precisely. I think a "clinical pathway" refers to an evidence-based approach to addressing one patient's one specific apparent need. But, what of the needs of a patient with multiple medical conditions? And what of the need to do aspects of planning that are not clinical in nature, such as discharge planning and financial planning? The idea to rationalize care in a larger context than is possible with our presently fragmented ecology of providers.

Elderly patients are likely to have multiple chronic conditions. Does "integrated care pathway" mean a customized clinical pathway that includes one patient's multiple conditions? Will there be computer applications such that one patient's mutliple conditions are input and the computer produces an integrated clinical pathway that seeks collapse multiple parallel pathways into one sequence of events for that specific patient? There are complex relationships among the many subsystems of the human body and individual differences among patients with similar combinations of conditions. Any attempt to optimize the way care is provided as related to multiple medical subsystems is going to require monitoring and real-time adjustment.

I am presently reading a book titled, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering by Hollnagel and Woods. The book is about cognitive networks that include both artificial and natural intelligence. When humans attempt to control a complex system they must be able to anticipate the "behaviors" of the various "agents" within the system. When some of the agents are computer programs that include artificial intelligence the ability to anticipate the behaviors of those agents can be difficult or impossible. Intelligence (artificial or natural) produces emergent behaviors, especially if the computer programming includes some generation of probability distributions, as when simulation software is used to control real systems. Not even computer programmers can fully anticipate emergent behavior and as a result "bugs" are sometimes defined to be unanticipated "features" of the software.

My conclusion at the moment is that we need to clarify terms like, "care pathway" so as to be more explicit regarding how ACOs are going to constrain costs and improve outcomes. The political case against the recent health care reform legislation was expressed as "bureaucrats" standing between physicians and patients. It seems to me that another aspect of concern is the prospective substitution of joint cognitive systems for the professional discretion of individual physicians. Is the phrase, "evidence-based" serving to help us feel more comfortable with a shifting from natural intelligence to artificial intelligence as we prepare to scale up our nation's healthcare delivery system? And how can accountability be assigned when care implementation is defined by joint cognitive systems including artificial intelligence? If the entire system is sufficiently complex, no part of it can be held responsible for adverse system outcomes.

Seeing Patterns in Data, Taking Actions in Life

As a university teacher I have taught on an number of campuses during my career. A few students remain in mind through the years for either having made a lasting positive impression or a lasting negative impression. I remember one student in a previous university employment who told me that as a public official her preparation for the prospect of a deadly epidemic would be to buy lots of coffins. I was at the time trying to teach her and other graduate students to use computer modeling to gain insights into dynamic complex systems so as to be able to take informed preemptive actions. In retrospect I realize that I should have been better prepared to demonstrate use of the software to my graduate students. But neither my colleagues nor my students seemed to appreciate the pedagogical use of computer simulations to help students better understand complex systems. I think now that if I had only shown students a computer simulation rather than asking them to think through the modeling of one the assignment would have been deemed acceptable. I have for years advocated that the academic field of public administration become more of a design science with ties not only to political science, management and business administration, but also to operations research. I take some comfort in the thought that Herbert Simon, if he were still with us and if he knew, would approve of my efforts, even if my efforts have on occasion contributed to the mobility of my career.

These memories were sparked this evening upon viewing the following TEDMED 2010 presentation. Jay Walker spoke of the origins of public health statistics using a Bills of Mortality book prepared during London's great plague of 1665. To me, his point is that data is the necessary basis of information that can support the knowledge needed to recognize patterns and design interventions.

If you would like to view the video directly from the YouTube site the URL is as follows.

http://www.youtube.com/watch?v=5IRsqDnPzSE

Tradeoff between quality of care and readiness to practice?

The following CNN Health report includes a CNN Radio report regarding new regulations limiting the lengths of shifts worked by medical interns and residents.

http://thechart.blogs.cnn.com/2011/06/14/limiting-student-doctors-hours-cuts-both-ways/?hpt=hp_bn6

The essential point is that while long shifts have been shown to contribute to medical errors that "shorter" shifts (say 16 hours at a time) will undermine the quality of the educational preparation of medical interns and residents. In a comment to the report "ramparts1815" stated that recent graduates know less and can do less than graduates five years ago. He or she adds, "And the public should realize that really good doctors and surgeons peak at 5-10 years after training."

As a university teacher I think a lot about the level of preparedness of new graduates. Something seems to be happening that is affecting the nature of the cognitive skills of emerging young professionals. Perhaps it is the cognitive overload of trying to digest so many streams of incoming information at a time. Even watching CNN television now involves continually receiving two or three news reports at the same time. Nicholas Carr suggests as much in his book, The Shallows: What the Internet is Doing to our Brains. It has been suggested that increasing rates of autism may be of environmental/chemical origin. If true, might the same chemicals be affecting the cognitive capacities/processes of all of us? Are we each losing individual cognitive capacity while our networked collective capacities are increasing?

To me, the bottom line is that if it takes increasingly long to educate physicians and surgeons and if their abilities peak and then tend to decline only five to ten years after graduation, we have problem. All things considered, if I have to be rushed into a hospital for some medical emergency I hope to be seen by people who are not so tired they cannot at that moment provide their wakeful attention. Nor do I expect when I go to a physician that others have perhaps endured medical errors in the past so as to somehow contribute to the quality of his or her education. I don't claim to have the answers here, but I wonder if there is something incorrect in the reported concern that when someone in training goes home for rest after a 16 hour shift that they do not adequately appreciate their needs to learn.

Scope of a Miracle

It is good to see photographs of U.S. Rep. Gabrielle Giffords that became available to the public today. Few people know all the details of the kinds of care she received that made possible the near miracle of her survival and recovery. There are surely many physicians, surgeons, nurses and others who together made this possible. She is alive and recovering today because of the coordination of the efforts of many professionals. In other words, it was not only the skills of individuals who saved her life and promoted her recovery. It was the timely coordination of those efforts. In this case, the "system" of care worked. I want to believe it would have worked as well for any person who suffered her injury.

As I read some of the comments received by HHS regarding proposed rules for implementation of ACOs I see the strong expressions of good people who simply do not want government agencies to attempt to rationalize the healthcare delivery system. Some people are simply opposed to "socialized medicine" and/or define the proposed changes as a loss of freedoms won on battlefields around the world. Others are open to change but do not believe that the new law and the proposed rules will work. Rep. Giffords' recent experiences with the system could be cited either as evidence that what we already have can work; or to say that we can do better. I want to believe that we can do better for at least all American citizens, including the large numbers of people entering the Medicare program. I believe that the rationalization of medical processes can reduce costs and produce more consistent quality outcomes for all patients.

It is a safe guess to say that the implementation of the new law will produce unintended behaviors among providers. The system that produced the law is a political system. Democratic political systems cannot produce scientifically rational policy designs, as in the context of operations research which is rational in a more objective way. Politics is the art of what is politically possible. As we pray and hope for Rep. Giffords' continued recovery let us continue to hope that the new law which she supported in Congress with her vote backed by her courage can be implemented successfully. "Bureaucrats" have to run with what they are handed by others.

What is the role of competition within an ACO?

I am reading the last chapter of the book Accountable Care Organizations: Your Guide to Strategy, Design, and Implementation by Marc Bard and Mike Nugent. It is well worth the time and thought to read. It appears to me that if they work, ACOs are more likely to be successful in large urban areas where there are large populations of people and large numbers of hospitals and physician groups. The idea is to scale up "production" by designing efficient and effective care pathways. In an urban setting multiple ACOs can exist and as a result there can be a constructive combination of efficiencies within ACO networks and constructive competition among multiple ACO networks. Hospitals and physician groups can "shop around" and even participate in multiple ACOs within a large urban market.

But it is not apparent to me that this is going to work well in smaller markets that lack enough population base to support multiple ACOs. If there is only one existing local hospital and no large physician groups then it appears that there is only one potential "game in town." The challenge there will be the usual one of trying to align the interests of physicians with the interests of the hospital, given shrinking revenue from government payers. But what about the situation in which there are two or three local hospitals in a city and they have a long history of unhealthy forms of competition including frequent law suits? To create an ACO governance body composed of people with long-standing local institutional loyalties is going to be difficult. I am concerned that Medicare beneficiaries and others in such places may lack adequate care because in the absence of an ACO local institutions will not have adequate financial resources to provide quality care. If long-term competitors cannot get past their issues and competitive interests they may be unable to form an ACO in small to midsize places.

Just as Certificate-of-Need legislation led to accelerated spending for costly medical technologies in the 1970s it will not be surprising if the Patient Protection and Affordable Care Act will lead to many attempts by local hospitals to buy out other local hospitals and local physician practices. Coordination that may not be otherwise possible is possible under unified ownership. But there are still laws on the books that prevent some acquisitions and that make it illegal for the very entities that should be talking about forming ACOs from discussing financial matters because such conversations would be anti-competitive. What it boils down to is, do we believe in competition or do we believe in networks based upon cooperation, coordination and trust. It seems as if we want hospitals to compete with each other while at the same time being partners within ACO structures. How can the people who govern an ACO also fulfill their responsibilities to individual institutions engaged in competition with ACO partners?

One of the things that Bard and Nugent advocate for is tightly coupled systems. Can a system be both tightly coupled and internally competitive? Is it reasonble to insist on what amounts to consolidation of institutions while at the same time forbidding hospitals and others from engaging in behaviors that are illegal because they threaten competition?

Helping Patients See the Light

Thomas Goetz of Wired Magazine spoke recently at TEDMED about the potential to leverage the voluntary compliance of patients by presenting them information that is personal, relevant and actionable. In my opinion, our nation cannot rise up to the challenge of providing quality medical care to all citizens without more effectively engaging patients as their (our) own best primary caregivers. Goetz points our that a sense of self efficacy is more effective in producing compliance behaviors (exercise more, stop smoking, and so forth) than is fear as a source of self motivation. Most people want to be healthy. Most people don't want to die a premature death. Goetz believes that "packaging" information for people is an effective way to gain compliance. I believe it is also a way to help reduce overall costs.

Direct link to YouTube video below

ACO regulation design flaw?

Paul Levy's explantion of a possible design flaw in the proposed rules by which ACOs may be regulated is worth exploration.

http://runningahospital.blogspot.com/2011/04/aco-rules-wheres-beef.html

It seems to me that the underlying problem is that many government policies intended to prevent constraints on competition just don't work well in the new paradigm of accountable collaboration. Is it possible that political realties make it impossible to achieve the needed combined goals of increased access, quality improvement and cost constraints? In light of national and global "graying," the reality is that as medical interventions become more successful people will live longer and costs will rise. It seems to me that there is an "impedance mismatch" between population-based healthcare and patient-centered medical care. On the one hand, when acute medical interventions become necessary we want assembly-line efficiencies. But on the other hand, we want to personalize care for each patient. Continuing discoveries involving DNA and genes can bridge the mismatch by allowing the creation of evidence-based protocols for very small groups of patients and even for specific individuals. But to do this the complexity of personalized diagnoses and treatments will increase dramatically, and with complexity the costs.

Yarnell Beatty Speaking on Accountable Care Organizations

Attorney Yarnell Beatty speaks here regarding what is now known and not known about Accountable Care Organizations, as outlined in the new healthcare policy.

Investigation of quality of care in Las Vegas hospitals

This is from Paul Levy's "Not Running a Hospital" blog. In the video below Brian Greenspun, Publisher and Editor of the Las Vegas Sun speaks about an extensive investigation of the quality of care delivered by hospitals in that section of Nevada by reporters Marshall Allen and Alex Richards and others. The essential message is that transparency and the willingness to face up to errors may actually reduce lawsuits and enables a hospital to learn from its mistakes.

Scientific Management, Systems Thinking and Evidence-based Practice

It is Friday evening. I am studying for a first set of questions in the course I am taking at Georgia Health Sciences University. The material involves an overview of the challenges of healthcare management and healthcare policy in the United States. At the moment I am wondering if evidence-based management (and evidence based clinical practices) are only new labels for the old scientific management. When Frederick Taylor calculated the optimal size of a shovel for a particular purpose was he not collecting evidence to be used in practice? And in a way were not his instructions to "Schmidt" (so as to get him to handle 47 tons of pig iron per day) somewhat analogous to telling instructing a manager or a physician in the one best way to do something, as derived from evidence? Is it a surprise that physicians resist systems by which they are evaluated upon compliance with procedures, especially when there are conflicts between the interests of particular patients and the financial interests of organizations?

http://www3.niu.edu/~td0raf1/labor/Story%20of%20Schmidt.htm

Evidence-based clinical practices are based upon observations of outcomes in large populations of patients. But physicians face their patients one by one. It is the particular patient that a physician is trying to understand so as to diagnosis and treat correctly. Under DRG's (diagnostic related groups), for example, the patient becomes a diagnosis. The correct evidence-based process is based not on the patient as a person but on a diagnosis. Many patients have multiple chronic conditions. If we go to evidence-based practice are we assuming that physicians lack the ability to use his or her systems thinking skills (informed by the evidence of personal experiences) to assess the needs of this patient. Does process ultimately replace cognition? Is the use of professional discretion something to be driven out of clinical processes as is variance in industrial processes?

I value evidence, process, efficiency and economy. But I hope that we are not driving good physicians out of the profession by constraints that may in a way reduce the profession to something of an industrial profession in which obedience is more highly valued than personal insights. Physicians rightly value professional discretion and autonomy. If we come to no longer trust physicians as human beings with advanced knowledge and cognitive skills, can we substitute a trust in evidence-based processes?

Summary of New Health Reform Law

Readers hoping to gain a better understanding of the new health reform law will be interested in this summary made available by The Henry J. Kaiser Family Foundation.

http://www.kff.org/healthreform/upload/8061.pdf

Reflecting on An Information Technology Implementation Challenge

This is an initial reflection upon an assigned reading by Ann Scheck McAlearney in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The title of the case is, "An Information Implementation Challenge." The focal character is Dr. Dan Johnson who has been appointed CEO of a hospital system. Johnson favors the adoption of new information systems including a computerized provider order entry (CPOE) system and or a more comprehensive electronic health record (EHR) system. The hospital system presently runs on paper-based systems and those systems are working. Dr. Johnson, a physician, is getting push-back from physicians and the supervisor of the medical records department. He has done his homework and can cite evidence that automated systems are better once through the period of deployment and transition. The case sets up a discussion of the challenges of transformational leadership. Those who are resisting a change have also collected "data" indicating that early adoption is problematic. Dr. Johnson favors early adoption and is planning his next steps carefully. He wants this to happen sooner rather than later. He realizes that if he pushes too hard he risks alienating good people whose work the success of the hospital system depends upon. He is inviting people to become part of a working group, but the key players he needs on board have strong reservations.

What is at stake is the future of the hospital system and the future of Dr. Johnson's career as an administrator. While some younger employees and physicians appear open to use of electronic devices the culture of the organization is not aligned with Dr. Johnson's plans. I see problems with all the "obvious" solutions. A likely future scenario is that he pushes forward quickly, the plan fails, the hospital system falters, and Dr. Johnson is forced to leave. The incremental approach (what Charles Lindblom termed, "muddling through") is not likely to be acceptable to Dr. Johnson. Sometimes you can't get from "here" to, "there" incrementally, and moving slowly becomes an excuse for not moving. Johnson should look for allies in other high places in the organization but he may not find any. It would be better if the energy for this initiative had emerged from within the organization and he had been "recruited" by others to become a sponsor. So far, his attempts to reason with people appear to not be successful. He is apparently not working from an external mandate that requires this change at this time. He is likely to call a meeting and find himself the lone voice in support of this idea.

I think Johnson has to assess the situation and consider that this fight may not worth the effort. Dr. Bernadine Healy, former president of the Red Cross, took on the culture of that organization trying to make needed changes and wound up sacrificing her career. If Johnson is indeed a lone voice in the culture of this hospital system he may be best for him to find another professional opportunity now. When reason is pitted against fear reason is likely to lose. The people who resist change are not bad, selfish or dumb. They prefer the known to the unknown. We all have a natural attachment to known ways of doing things, even if we realize that the status quo is not ideal. Concerns about job loss or spending less time in direct patient care are realistic concerns. Automation involves process reengineering which often results in reducing the number of employees and modifying the responsibilities of those who remain. Physicians rightfully value their autonomy and resist changes that may force them to explain some of the decisions they make regarding their patients. Transformation is costly and requires faith that the gain will ultimately be worth the pain.

It appears from the case study that Johnson has the ability to listen. It is necessary to listen in order to gain empathy for others. The key is to create an alignment of interests if possible. I am not recommending a political approach such as Nancy Pelosi collecting Congressional votes for healthcare reform one deal at a time. But I question that Johnson can win this one based on evidence-based management alone. He must address peoploe's fears, including possible job loss and possible reductions in professional autonomy. The external environment of healthcare organizations is changing rapidly. Organizations must adapt. By adapting they have some ability to affect environmental changes. A failure to adapt is risky. I am remembering the movie, "Other People's Money." Clinging to a dying organization is futile. As a physician Johnson had to make difficult decisions involving the best interests of patients. Now as an administrator he must make difficult decisions involving the best interests of a hospital system. He has to assess what is possible and what may not be possible. He has to assess how important the future of this particular hospital system is to him. It is not selfish to walk away from one situation to join another organization more ready to accept one's heart-felt beliefs. I believe Johnson needs some internal allies to be able to make this change.

There is an episode of the original Star Trek series in which Captain Kirk materializes in some strange parallel universe by a malfunction of the transporter. Spock and other team members in that other universe are evil deriveratives of the characters we know. Spock of the other university figures out what has happened and arranges for Kirk and others to return to the right universe. The following dialog is part of this episode named, "Mirror, Mirror."

KIRK: You're a man of integrity in both universes, Mister Spock.
SPOCK: You must return to your universe. I must have my captain back. I shall operate the transporter. You have two minutes and ten seconds.
KIRK: In that time I have something to say. How long before the Halkan prediction of galactic revolt is realised?
SPOCK: Approximately two hundred and forty years.
KIRK: The inevitable outcome?
SPOCK: The Empire shall be overthrown, of course.
KIRK: The illogic of waste, Mister Spock. The waste of lives, potential, resources, time. I submit to you that your Empire is illogical because it cannot endure. I submit that you are illogical to be a willing part of it.
SPOCK: You have one minute and twenty three seconds.
KIRK: If change is inevitable, predictable, beneficial, doesn't logic demand that you be a part of it?
SPOCK: One man cannot summon the future.
KIRK: But one man can change the present. Be the captain of this Enterprise, Mister Spock. Find a logical reason for sparing the Halkans and make it stick. Push till it gives. You can defend yourself better than any man in the fleet.
SCOTT: Captain, get in the chamber!
KIRK: What about it, Spock?
SPOCK: A man must also have the power.
KIRK: In my cabin is a device that will make you invincible.
SPOCK: Indeed?
KIRK: What will it be? Past or future? Tyranny or freedom? It's up to you.
SPOCK: It is time.
KIRK: In every revolution, there's one man with a vision.
SPOCK: Captain Kirk, I shall consider it.
(He beams them away.)

http://www.chakoteya.net/StarTrek/39.htm

Cultures change slowly, but they can change. One voice can possibly initiate a change if joined by other voices. In the case study, Johnson may find a way to change the culture of the organization he leads. Johnson has power but his power is derived from the support of those he leads. He appears to have the sensitivities needed to understand the situation in a systematic way. Logic may gain its end and his vision may be realized.

Reflecting on Evidence-based Management

This is an initial reflection upon an assigned reading by Kovner and Rundall in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The essence of the reading is that healthcare managers should make decisions based upon evidence just as physicians should practice evidence-based medicine. Basically this means there should be close ties between scholarly research and managerial practices. My approach to this is shaped by my experiences as a academic person who teaches public administration.

If there is a disjoin between scholarly research and managerial practice the easy explanation is to fault practitioners for not reading academic journals. It is not that simple. Even in public administration (PA), which is an applied field of study and practice, there is a substantial divide between scholarship and practice. The best practitioners were often not outstanding students. Successful PA scholars are not necessarily able to make a transition to successful practice. Success in scholarship requires a deep, narrow focus. Success as a practitioner requires a wide variety of interests and abilities. Scholarly journals are much more geared toward the needs of academic persons than practitioners. Even in PA, an article seldom includes an "executive summary," to clearly identify the relevance of findings to practice. Getting a paper published in a scholarly journal often requires the use of advance mathematics in the data analysis. Few practitioners have either the need or the interest to work through the mathematics. The bottom line is that practitioners are more likely to learn through informal communities of practice than by reading articles written by academics as required to advance their academic careers. Peer-review does not usually include practitioners as reviewers and what is required by peer-review to get work accepted for publication is sometimes not as rational and scientific as the public may assume. Assuming that what I have observed in PA applies to healthcare management the status quo does not favor greater use of evidence based management practices. As indicated by Kovner and Rundall, healthcare managers claim to practice evidenced-based decision making but do not cite scholarly research as the evidence they draw upon.

If a disjoin exists between research and managerial practices I believe the scholars must accept at least part of the responsibility for closing the divide. Academic cultures are probably among the most durable of all organizational cultures. It is unlikely that in the near future tenured or tenure-track faculty members will be rewarded for their abilities to span related areas of knowledge or to contribute to successful practice. If this is correct, this is sad. There is a degree of distain for academic "ivory towers" among some practitioners. And there is a degree to which some scholars look down upon successful practitioners. It is cause for concern when former students who did not display advanced cognitive skills as students sometimes move quickly into high-paying positions with major responsibilities. While evidenced-based management practices are surely important they are probably not highly correlated with successful careers as practitioners. "Success" of course can be defined in different ways, but that is probably more evident to scholars than practitioners. If the major institutions of society were ever managed by persons with the most advanced cognitive abilities it appears that those entering the systems now may be less well prepared to practice evidence-based management. If there is a gap between research and practice it is the responsibility of all concerned to try to address that divide.

Addressing the Challenges of Multiple Chronic Diseases

This is a reflection on the article, "The Growing Burden of Chronic Disease in America" by Gerard Anderson and Jane Horvath, Public Health Reports, May-June 2004, Volune 119. The essence of the article is that a growing percentage of Americans have multiple chronic diseases; that the costs of treating people with multiple chronic diseases is high; that people with multiple chronic diseases usually see multiple physicians; and that physicians are not very successful in coordinating their efforts with one another to address the needs of specific patients. The theme here is complexity.

The human mind/body is a complex system. Physicians always take into account the complexity of multiple body systems when addressing a single medical need. But when the same body has multiple needs the complexity of interactions among the conditions drives up the complexity of trying to help the patient. And then when multiple physicians become involved (and multiple medications are prescribed by various physicians) the entire situation is likely to get out of hand. The patient is the center of the system of care but is unlikely to have the knowledge necessary to try to orchestrate the entire effort.

W. Ross Ashby introduced his Law of Requisite Variety in about 1958. The law states that if a system is to be stable the number of states of its control mechanism must be greater than or equal to the number of states in the system being controlled.

http://en.wikipedia.org/wiki/Law_of_Requisite_Variety#The_Law_of_Requisite_Variety

In the case of a patient with multiple chronic conditions, it follows from Ashby's Law of Requisite Variety that the coordinated medical care delivery system (the "control mechanism") must be at least as complex as the human body as a macro system (system of systems). Well, we are going to lose that one!

I believe there is another approach. It is root cause analysis. What becomes manifest in a patient as multiple chronic conditions may be the product of a few root causes. Stephen Wolfram has demonstrated that recursion among a very few simple rules can produce very complex fractal patterns. A chronic condition (or a combination of them) may possibly be interpreted as complex fractal patterns derived from a relatively few root causes.

http://en.wikipedia.org/wiki/Cellular_automaton

While reflecting on the article by Anderson and Horvath I am wondering if it may be possible to make clincal applications of root cause analysis in the treatment of patients with multiple chronic conditions. As it is, these authors are advocating addressing complexity with complexity, as per the insights of Ashby. Medical conditions are products of causal trees. If physicians aim too high on the causal trees they are likely to produce cascading complexities. It is the difference between the perspectives of physics and the other sciences. While others see complexity, physicists search for the simpicity from which complexity springs. If it is possible to aim closer to the roots of causal trees it may be more feasible to address the needs of patients with multiple chronic conditions more effectively.

The Roles and Responsibilities of Managers

Our reading assignments this week in the class at Georgia Health Sciences University regard the role of managers in healthcare organizations, including aspects of control, design, professional integration, adaptation and accountability. One of the points made by the authors of our textbook (Kovner, McAlearney and Neuhauser) is that the measurement of aspects of processes and outcomes is important in assessing quality of care provided. I have no doubt that Lean Six Sigma, the Toyota Way, balanced scorecard and other similar management tools are valuable. But there is also a lot to be said for just good old common sense. I wonder if managers don't sometimes become so detached from what is really happening in the organization that they miss the obvious. Bureaucratic and highly regulated organizations can create people so fixated on rules and procedures that they can miss what is obvious and common sense.

I am remembering the statement of "Dr. Leonard McCoy" in Star Trek IV: The Voyage Home as the crew is pondering what their next ship will be. "The bureaucratic mentality is the only constant in the universe. We'll get a freighter." My point is that the foundation of good management is good sense. If someone steps forward and identifies a problem or an opportunity there are probably many others who share the observation and for whatever reason have not expressed the obvious. In my opinion, good managers do not thrive on rules. Over time, they shape the culture of an organization in such a way that that common sense and shared values reduce the dependence on rules.

There is a Taco Bell store in Albany that I like. The people are friendly and the food is good. But there is one light fixture that customers are always bumping into. Its placement is a design flaw. It is suspended at a height of less than six feet. It is in the exact location that people walk to get to a table and then to place used cups and papers in the waste can. Many people bump into it. It is so obvious that it needs to be either raised or removed! There is no need for a customer satisfaction survey asking whether you enjoyed bumping your head into a light fixture today. I have asked managers at the Taco Bell store at least five times to either raise or remove the light. I have sent e-mail to "Taco Central" with the same plea. Nothing happens. Either the local managers don't care or they are powerless to take such a radical initiative as to raise a lighting fixture.

I bet there are plenty of situations like that in hospitals that managers miss because they are watching the numbers rather than looking up and seeing the obvious.

iPhone ECG Application

My guess is that apps will also be written for purposes of verifying medical compliance. For example, Medicare does not want to continue to pay for CPAP devices that are not being used by patients. An application could be created that would interface with the SD card in the machine to verify that the patient has actually used the machine at least four hours a night.

Making Sense of Hospital Charges Data

This blog post is related to a reading assignment in a course I am taking online taught at Medical College of Georgia -- soon to become Georgia Health Sciences University. The article which was published in The New York Times is titled, "In Health Care, Cost Isn't Proof of High Quality." This article by Reed Abelson observed that there is substantial variation in the costs of various medical services among institutions and that higher costs do not necessarily correlate with better outcomes or higher quality of care. The data was derived from reports submitted by hospitals in Pennsylvania.

http://www.nytimes.com/2007/06/14/health/14insure.html

http://www.phc4.org/reports/hpr/09/

Abelson's point appears to be that payers are questioning why they are apparently sometimes paying providers relatively larger amounts of money for medical services that do not appear to be producing better outcomes overall. The data is reported by procedure/treatment, by hospital.

The measures of quality of care include mortality rating, length of stay, and readmission ratings -both for any reason and for reason of complication or infection. Average charge per case (for each selected medical procedure/ treatment) is shown for each surveyed hospital. The data reflects risk adjustment factors for all of the variables. The data is for fiscal year 2009.

So, what are people to make of this? In many instances the number of cases of a particular treatment in FFY 2009 in a given hospital is very few. Averages based upon a very few cases can be dramatically skewed by one or two exceptional cases. The data is reported in a way that is a bit confusing because unexpected high rates of short average lengths of stay are appear with the same large dark circle that otherwise is used to represent high mortality rates and high readmission ratings. It is hard to interpret the data by just looking at the representation of it, which resembles the way years/models of automobiles are rated in Consumer Reports publications. It does not appear to me that high mortality rates tend to be associated with either higher or lower costs per case. Nor does it appear that average length of stay correlates with average charge. It does not appear that the number of cases treated in FFY 2009 is correlated with any of the other data. It would take a substantial amount of quantitative analysis to test hypotheses for each procedure and treatment. It would be helpful if the data that has been published was aggregated by hospital rather than only by procedure/treatment.

My guess is that detailed quantitative data analysis would not produce any clear explanation of why some hospitals charge substantially more (on average) than others for the same procedures/treatments. I think a qualitative approach to data analysis might produce more insights. I suggest identifying the hospitals that tend to produce higher charges across most categories of procedures/treatments and then ask insiders what other attributes those hospitals share. They might be hospitals that provide high levels of charitable services and need to shift the cost burden onto patients with insurance or other sources of revenue. They might be hospitals that offer up-scale accommodations. They might tend to be for-profit hospitals, or hospitals deeply in debt. Given the list of the "high chargers," I bet one or more explanatory themes would quickly become apparent.

Anticipating "Black Swan" events

Nassim Nicholas Taleb's best-selling book, The Black Swan: The Impact of the High Improbable(now in its second edition) regards the anticipation of low-probability, high consequence possible events. Managers generally focus their attention on the crisis of the day and on likely near-future scenarios. There are so many low-probability possible scenarios that it may not be a productive investment of time and attention to give them much thought. It is difficult to plan for a radical change in circumstances. And an executive or manager is not likely to be faulted for failing to anticipate an event that was very improbable before its occurrence.

But medical insights are evolving rapidly. For example, the discovery of a cure for aging, resulting in radical life extension, would certainly have huge consequences to medical institutions and societies at large. It would probably result in a large increase in numbers of people with chronic medical conditions and would surely lead to substantial population growth, further taxing the limited resources of the earth. It could happen. Many unlikely things of high potential consequence are possible. Some of the work being done in theoretical physics would surely have dramatic consequences if radical new ideas could be implemented.

Healing the Body Politic

As I write this Gabrielle Giffords is in an ICU unit and expected to survive. Americans and others are praying for her recovery and remain mindful of those others who were shot recently. Physicians and other medical providers and administrators who helped save Representative Giffords life are to be commended. This includes the legislative intern with some medical training who was with her at the time of the shooting. With others, I am trying to derive meaning from what is happening in our nation and around the increasingly interconnected world.

Medicine is the art and science of healing. Distress is fractal and exists at the scales of individual and society. Our "body politic" needs healing. I find it odd that some now reason that it is the specific motivations of the shooting suspect that will determine whether or not the shooting was related to political issues, including healthcare reform. Words and images have consequences. The scope of our inquiry and concern is not the thought patterns of one apparently disturbed young mind -- that of the suspect in this case. The person is probably mentally ill and his motivations do not define the larger reality. As Representative Giffords said prior to the shooting, words and metaphors have consequences. This is about a fractured body politic. While we cannot expect neurosurgeons to heal our nation we can perhaps learn from medicine by seeing healing in a larger context.

Representative Giffords' MSNBC Interview following Healthcare Vote

The Power of Memes

Many Americans and others around the world are trying to make sense of the killing of six people and wounding of twelve people in Arizona yesterday. We continue to think about and pray for all the victims and their families, including Representative Gabrielle Giffords. The tie to this blog, of course, is the fact that her support for passage of the recent health care reform legislation may be related to recent events. I have been thinking about why health care reform is such a sensitive issue and has such power to shape political and social divides in our nation.

A meme is an idea that seems to have a will to proliferate itself and to survive. We do not often think of ideas as having a will. But it can be insightful to consider them that way. Successful religions can be thought of as systems of memes that have evolved over time and that are especially good at reproduction and defense. For example, "go forth and multiply" is a meme and an important part of a meme system because a person's children are likely to carry the same memes as the parents.

Political ideologies are also meme systems. The virtue of gun ownership, for example, has apparently become a political meme important enough to be a criterion for the selection of president of the Republican National Committee. To the encouragement of the audience the candidates for the position recently either lamented their having an inadequate few guns or boasted of the number and fire-power of their personal collections of guns. The "gun ownership" meme is apparently thriving in at least one sector of American political ideology.

I am reaching here to try to understand why health care reform is such a hot-button issue in America today. Obviously, it is important because we realize the importance of medical care in our lives and we fear for the loss of access to costly resources. But, there is more to it than that. I believe that health care debates are intense in a democratic society because they involve the clashing of powerful meme systems.

This is like chemistry. I remember from childhood experiments that the mixing of the content of two containers can have very dramatic results. Memes and systms of memes have powerful survival instincts and when threatened defend themselves at all costs. I don't know exactly what the "powers and principalities" phrase in the Bible refers to, but memes, while hosted in "flesh and blood" are more than flesh or blood. It is the idea that you can kill a person but you cannot kill an idea. Responsible people who would become our leaders need to be very careful in the use of words and images. It is not just because there are some mentally unstable people out there. It is because memes can be like dangerous biological viruses. Substantial numbers of people cannot deal with complex reasoning and take what may be intended figuratively as literal.

The Internet is the ultimate meme machine. It puts democracy on steroids, for better or for worse. The "market place of ideas" argument is that in a free-for-all among all kinds of ideas the reasonable, rational ones will win. Not necessarily. The memes and meme systems most carefully designed for replication and survival will win. From the perspective of a meme, we are only hosts. Meme systems are complex and adaptive and exist in a common ecology of thought-space. I am concerned by what is happening in the thought-spaces of humanity and I see evidences of "bad chemistry" in many events including the shootings in Arizona yesterday. Public policies are shaped by competions among ideas and the formulation of public policies exert pressures upon highly defensive meme systems. Our leaders (and all of us) need to be careful in our use of words and images.

Democracy as faith

I see the next few years as a critical passage for America's experiment with democracy. The Republican Party is being pulled further toward absolutist perspectives by Tea Party members. The election of a President Sarah Palin in 2012 is a real possibility. Her "death squads" references (as related to healthcare policy) hit a chord among many people.
Around the world we see examples of people in Western Democracies assuming a childish perspective that government can and will make life easy. Reality is not simple and political leaders have limited abilities to, "make it better," like mommy kissing a hurt. At some point, fiscal conservatism is going to run headlong into social conservatism. Medical realities demand difficult choices. It is not possible to maximize quality, accessibility and affordability all together. I am concerned that the nature of political discourse in the United States in the near future is going to strain the fabric of democracy.

Death of Birds not a Laughing Matter

I think the treatment of the death of birds falling recently from the sky in Arkansas on David Letterman's show is stooping to a form of sick humor not worthy of a professional person or a responsible television network. The preliminary explanations of the event are pretty lame. "Oh, they died of trauma or were startled by a loud noise." Well yes, falling out of the sky onto the earth is likely to produce evidence of trauma. Something caused them to fall and the event is dramatic evidence that we really should figure out and face up to the cause of the event. My guess is that an unusual burst of microwave radiation may be the explanation. Whatever the cause it can't be good for other life forms including humans. Let's figure out what really happened.

Doctors begin to embrace the Web

This news story appearing on the Kaiser Health News site makes the case that it is convenient for patients to be able to view their physicians' schedules and make appointments online.

http://www.kaiserhealthnews.org/Stories/2011/January/03/zocdoc.aspx?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+khn+%28All+Kaiser+Health+News%29&utm_content=Google+Feedfetcher

Physicians can make this service available to patients through a vender called ZocDoc at a cost of about $250 per month. Nearly 85 percent of appointments made on ZocDoc are made by new patients. The service provides patient reviews of physicians on their site.

The day will probably come when physicians make themselves available to communicate with patients by e-mail in appropriate situations. This is more feasible under some payment plans than others. And then there are the issues of legal liability. I wonder if e-mail communications with patients become part of the patient's record. If yes, and this happens by automation, there may be some risk to patients in terms of making ungrounded information about themselves available to insurers in a way not interpreted by the physician. Patients may speculate about things in an office visit that the physician knows need not (and should not) be entered into the record. If medical services tend to move online those ungrounded speculations by patients may be more likely to become part of a patient's medical record. The value of a person's medical record is a function of professional choices about what is included. If the record becomes bloated with content that should not be included the next step is likely to be automated searching and summary services. Artificial intelligence is not to a place where this prospect is attractive. It seems to me the solution is for e-mail communications between physicians and patients not be entered into medical records automatically.

USMLE Medical Ethics test preparation guide

Book review: USMLE Medical Ethics test preparation guide by Conrad Risher, M.D. and Caterina Oneto, M.D.


(Image derived from Amazon.com portal.)

This book is intended to help medical students prepare for the to pass the MSLE™ Medical Ethics part of the standardized examinations required as part of their medical educations. It would be unfair to fault this good book for it not being the kind of scholarly work it is not intended to be. It contains insightful explanations of a variety of the ethical and legal situations physicians encounter. The chapters are devoted to the following topics.

• Patient autonomy
  
• Patient competence and the capacity to make decisions
  
• Informed consent
  
• Confidentiality and medical records
  
• End-of-life Issues
  
• Reproductive issues
  
• Organ and tissue donation
  
• Reportable illnesses
  
• HIV-related issues
  
• Sexually transmitted diseases
  
• Malpractice
  
• Doctor/patient relationship
  
• Doctor and society
  
• Doctor/doctor relationship
  
• Experimentation
  

Following the fifteen chapters the book concludes with 100 questions of the type likely to be included on the test. Following the entire set of sample questions are correct answers and meaningful explanations of why the correct answer is the correct answer.

While this book is not intended to include ethical and legal aspects of health care administration I believe it is well worth being read by people preparing to become healthcare administrators. The book is available from a variety of sources.

Note: I derive no revenue from this blog. This is not a commercial post. - bjn

Time for new physicians to have normal schedules

This news story reports the consequences of surgeons and other physicians working with sleep fatigue.

http://www.cnn.com/2010/HEALTH/12/29/sleepy.surgeons/index.html?iref=allsearch

Maybe there was a time when students completing their medical educations worked long hospital shifts for some reason. Maybe it was some kind of rite of passage. But, in my opinion, all physicians (and other medical professionals) owe it to their patients, their institutions and themselves to work a normal schedule. This is not like students at law schools being required to provide some free legal services prior to graduation.

In my opinion, these are the likely consequences of medical students being required to work excessively long shifts prior to completion of their degrees.

1) Unnecessary risks of medical errors placing patients at medical risks and institutions at financial risks.

2) New physicians becoming alienated from sources of administrative authority, making future collaborations with hospital administrators more difficult.

3) The conclusion from one's required educational experiences that it is okay to work in an impaired condition.

Would we want new pilots preparing to be employed by commercial airlines to be required to fly and land aircrafts full of passengers to demonstrate their ability to function when deprived of needed sleep? It should not be necessary for patients to call their doctor's office asking whether he or she is scheduled to be on call the night before a scheduled surgery. Legislation should not be required to require hospitals to assure that their employees are not sleep deprived. It should not be necessary to train surgeons that they should not be performing surgery when half asleep. There is a statement in the news story attributed to Dr. Charles A. Czeisler saying that, "Asking a surgeon to decide whether they're fit to perform elective surgery after having been up all night would be like asking a bartender asking somebody who's legally drunk whether they can safely drive home." If what this statement suggests is true of even a small minority of physicians it is a shocking reflection on medical professionalism.