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.