Healthcare & IT: Oil & Water?

I don’t think it has to be that way, but the history of IT adoption and implementation in healthcare might lead many to believe otherwise. True, there have been major advancements just over the past decade, but from a public policy perspective, have federal policy initiatives helped – or hindered – that progression?

I think most everyone would agree that information technology holds great promise in improving the value of healthcare delivery. And by greater value I mean assisting caregivers and clinicians produce better outcomes at lower cost. Except that in many instances it’s not working that way.

Practical Experience
Courtesy of the healthcare policy-oriented site,
KevinMD, I recently came across a blog post by Dr, Christine Sinsky that made me decide it might be a good time to bring this topic up again with you. Dr. Sinsky’s blog post, Hazards of Poorly Designed Decision Support, is an anecdotal yet nonetheless compelling reality of IT utilization in healthcare. The decision support system in question is Trinity Health’s mandatory DVT Advisor.

DVT stands for deep venous thrombosis, which in laymen terms means a blood clot that that forms in a vein deep inside a part of the body. DVTs are most common in adults over age 60 but can occur at any age. If the clot breaks off into the bloodstream, it is called an embolism, which can get stuck in the brain, lungs, heart, or other area, leading to life threatening situations.

DVT Advisor was implemented in response to Meaningful Use requirements. You can read Dr. Sinsky’s post if you would like to understand the practical frustrations she found in using it, but for the purpose of this post I will summarize the key points.

From her perspective (my interpretation now) there are two key areas of the system that are counterintuitive to facilitating value creation as I describe above: unnecessary input requirements and decision tree logic rigidity that was unable to capture and reflect the patient’s situation (i.e., usability challenges). In essence, the system created more work – and more importantly, introduced a new level of potential risk – than would not have existed without its use. Now that, Pub patrons, is what’s known in laymen terms as, “stupid.”

In the interest of fairness and disclosure I want to note that Dr. Sinsky was complimentary of certain elements of the system; e.g., “the information in the DVT Advisor can be a useful reference if a physician is uncertain about anti-coagulation, but its intrusive and insistent characteristics are based on hope and belief, rather than evidence.”

Policy Issue
And so here’s the policy issue: you have an IT decision support tool that has the potential to add value but for the fact that its design has actually lowered it. Now,
I have been an ardent proponent of supporting advancements in HIT as a primary means of improving productivity and efficiency – and thus lowering care delivery costs. I have been less enthusiastic about the top-down approach of HIT policy the federal government has employed to advance those efforts. I have also believed, however, there is the need for an active role of government in helping advance health IT adoption. The what and the how of that role is less certain today.

So for me, Dr. Sinsky’s post is not the needle-in-the-haystack that generated an intellectual epiphany on my part regarding the effectiveness of HIT policy efforts. There is more than enough research and literature supporting logical skepticism for the open-minded to consider. Rather it was more of the straw within the haystack that broke the camel’s back. I am looking for some pub patrons that understand this subject-matter much better than me to weigh in here.

There are some of the most brilliant minds in the world working in HIT – in the clinical and nonclinical arenas – but I sometimes wonder if they can’t get out of their own way to understand the pragmatic nature of value creation. And I wonder if federal policy and governmental agencies haven’t been just willing abettors counting more on hope than evidence as Dr. Sinsky points out.

Please, prove me wrong – show me the evidence where HIT public policy has been more effective than not.


P.S. Please click on the hyperlink above associated with Dr. Sinsky’s name. This will take you to her website where there is a wealth of information on HIT based upon her and her husband’s professional contributions.

Can Big Data Rescue Long-Term Care Providers?

Big Challenge
Yesterday, the
Alliance for Quality Nursing Home Care announced the release of a new study from Avalere Health, which projects a $65 billion cumulative reduction in Medicare funding of skilled nursing facility reimbursement over the next ten years. The cuts are projected to result from implementation of the Affordable Care Act’s productivity adjustment ($35.3 billion); the regulatory case-mix adjustment enacted in FY 2010 ($17.3 billion); a CMS forecast error adjustment in FY 2011 ($3.2 billion); and the sequestration provision of the Budget Control Act ($9.8 billion).

Several news sources have picked up the Alliance’s press release and noted those states with the highest levels of projected annual cuts, e.g., Florida ($370 million), California ($350 million), Texas ($240 million), Illinois ($240 million), New York ($220 million), Pennsylvania ($200 million) and Ohio ($200 million).  I don’t think the aggregate comparisons are necessarily very useful because there are a host of other considerations that should be included to truly understand the relative impact of these reductions on individual SNF providers in each of these states.  What is quite meaningful, however, is the stark reality the industry is facing: the decade ahead will see tremendous operational and economic challenges as providers try to accommodate the demographic realities of increasing demand at the very same time less resources are available to cover costs.

Big Data to the Rescue?
In the July 2012 issue of HealthLeaders Magazine Philip Betbeze writes about
Healthcare’s Big Data Problem.  Well, it’s a problem in so much as substantial obstacles still stand in the way of being able to use healthcare data more effectively – and more pointedly, to the real time benefit of operational, financial and clinical decision making.

If I could sum up that challenge it would be this: how do you take an unparalleled amount of disparate  data (e.g., demographic, operational, financial, clinical) and meld it together into a warehouse of information, such that the various elements of that information can be combined, compared and contrasted in ways that reflect and then empower the distinctive thought processes of clinicians, managers and executive leadership of healthcare organizations?

As the article points out, some very encouraging progress is being made to overcome this challenge, including something called, “natural language processing technology,” which integrates clinician notes from the patient’s EMR into the aforementioned information warehouse.  This could be a huge step forward because it has the potential to address a major obstacle sited by many clinicians: i.e., the ability to effectively capture and later be able to quickly recall and share ad hoc note taking that is such a critical component of a patient’s record.

When looking at the path from data to actionable knowledge it is important to remember that data becomes information only after it has been collected, aggregated and organized.  Information becomes knowledge through analysis.  Knowledge becomes wisdom through synthesis.  Wisdom is the foundation of economically beneficial decision making.  Unfortunately, effectively navigating the winding path from raw data to informed decision making has a lot more to do with human nature and individual personalities than it does with the ability to store and manipulate binary data bits.

The Big Idea
So what does this have to do with post-acute and long-term care? As many providers are beginning to realize – and some I dare say, even accept – the economic future of healthcare delivery is going be built upon value-based incentives and risks.  Ultimately, the distinctive difference between financial sustainability and going out of business will depend on the ability of direct service and care workers – whether that is the medical director or the food service aide – to make real-time decisions that allocate the organization’s resources in ways that add value and minimize risk.

Empowering those individuals with the requisite knowledge (see above) to make those decisions more quickly, more confidently and more in alignment with the organization’s value-based mission will create competitive advantages that lead to comparatively stronger financial performance under value-based contracting and integrated care delivery models.  This is a critically important consideration to have in mind when beginning to explore potential relationships with other healthcare providers in your market. 

It is likely that many if not most post-acute/long-term care providers will have to link into and utilize the Big Data solutions of more formidable acute care organizations.  In doing so, PA/LTC organizations must be in a well-informed position so that they can clearly articulate how such solutions must serve them and their direct service and care workers as a prerequisite to their adding value to an integrated delivery network.  It fundamentally has to be a core element of the negotiating process.

So my advice to the leadership of PA/LTC organizations is straight forward: if you don’t yet realize and understand the impact that emerging Big Data solutions will have on how well you are strategically positioned to compete in a value-driven world of healthcare delivery and integrated models of care – learn quickly.  Or, as an alternative, find someone you trust who does – and listen to them.

That’s what I think, anyway.  Would love to hear what you think!

  ~ Sparky

Don’t Let Data Get in the Way of Good Judgment

There was an interesting article in the April 2012 issue of Harvard Business Review (Good Data Won’t Guarantee Good Decisions, by Shvetank Shah, Andrew Horne, and Jaime Capellá) that I think has relevancy to post-acute/long-term care providers.  Specifically, insights there can be useful in better understanding the significant clinical and operational challenges associated with developing the type of IT infrastructure that will help those organizations demonstrate real value as participants in integrated care delivery models.

About the Article
The authors are part of the leadership team at the
Corporate Executive Board
and they share some of what was learned through development of a proprietary tool used to assess the ability of employees to, “find and analyze relevant information.”  They call this the, Insight IQ, and through researching 5,000 employees at 22 global companies they stratified those employees into three types:
     Unquestioning Empiricists: Trust analysis over judgment
     Visceral Decision Makers: Go exclusively with their gut
     Informed Skeptics: Balance judgment and analysis

They argue that the Informed Skeptics are, “best equipped to make good decisions,”  but that only 38% of employees – and 50% of senior managers – fell into this group. Their research also uncovered four problem areas that represent obstacles to achieving better ROI on IT expenditures to develop data analysis:
     Analytical skills are concentrated in too few employees
     IT needs to spend more time on the “I” and less
on the“T”
     Reliable information exists, but it’s hard to locate
     Business executives don’t manage information as well
they manage talent, capital and brand.

Implications for PA/LTC Providers
As I have written in this space previously (and in other publications), PA/LTC providers face a challenging Catch-22 with respect to Information Technology: how to make prudent investments that position them to be competitive in a world of integrated care delivery without subverting scarce resources during a period of tremendous financial pressure.  In making such investments it is critically important to fully understand and anticipate how future IT functionality will enhance clinical and operational capabilities.

To really create demonstrable value as part of an integrated care delivery network it will not be sufficient to collect, assess, analyze and report data collected through an EHR/EMR system.  Those providers seeking to gain a distinct competitive advantage through IT capabilities will also need to demonstrate how their IT infrastructure supports tangible achievements, e.g., greater patient activation, operational efficiencies and improved productivity, higher stakeholder and constituency satisfaction scores and lower rates of hospital readmissions.

As I wrote in my recently published white paper: Strategic Planning and Positioning for Healthcare Reform,
     Data becomes Information when it is organized
     Information becomes Knowledge when it is analyzed, and
     Knowledge becomes Wisdom when it is synthesized.

The stakes are very high for PA/LTC providers entering the new world of integrated care delivery.  IT investment is a foregone certainty of participation – and with that comes the tremendous risk of not achieving the necessary ROI.  As the article points out, “investments in analytics can be useless, even harmful, unless employees can incorporate [those analytics] into complex decision making.”

And there are few industries where the complex decision making of employees carries as much importance (and risk) as in healthcare.  When developing your organization’s IT Strategy, therefore, it is very important to do so in a way that sufficiently recognizes and incorporates operational and clinical understanding.

Policy Implications
There is a lesson here, too, for public policy initiatives seeking to drive wider adoption of Evidence-Based Healthcare (EBH) and Evidence-Based Medicine (EBM). Direct caregivers – and in particular physicians – are being pressured to make greater use of EBH/EBM.  We see this in the regulatory platform of the Shared Savings Program (i.e., Medicare ACOs).  We see it in how the Insurance Exchanges are being built.  And we see it in how Minimum Essential Benefits have been defined.

I believe most physicians rightly view themselves as Informed Skeptics: balancing available data with their practice experience.  I think where very often a policy disconnect occurs is when physicians try to paint policymakers with the broad brush of being Unquestioning Empiricists: seeking to supplant physician judgment with mandated decision trees.  In response (retaliation) then, policymakers will often argue that physicians’ Visceral Decision-Making is used as a cover for the economic benefits of fee-for-service based medicine.

Of course, reality as usual, lies somewhere in the middle – beyond the interests of political campaigning.  I have always argued against mandated third-party protocols (i.e., those not created and implemented by healthcare providers) because I believe the Visceral Decision Maker brings more to the table than the authors’ research necessarily implies.  I am mindful of Malcolm Gladwell’s book, Blink, in which he explains the importance of rapid cognition and intuition – and how these capabilities are based on a lifetime of experience that exists in our subconscious.

But the key takeaway here, from a policy perspective, is the importance of going beyond the “data,” which constitutes the evidence in EBH/EBM, and understanding how data will (can) be used in provider decision-making.  The same caution that applies to organizations of being at risk of data getting in the way of good decision making thus applies equally to the development of effective public policy.

What do you think?

  ~ Sparky

Chronic Care and Technology

Whenever I think about Healthcare and Technology I am reminded of a wonderfully poignant joke that Rita Rudner (think, Rodney Dangerfield’s Young Comedians Special back in the 1980s) used to share:

"They’re trying to put warning labels on liquor now. ‘Caution: Alcohol can be dangerous to pregnant women.’ Did you read that? I think that’s ironic – if it wasn’t for alcohol, most women wouldn’t even be that way."

If it wasn’t for advancements in Medical Technology – and the attendant increase in life expectancy – one has to wonder whether the much maligned Cost Curve would hold sway over our social and political anxiety as it does today.  Undoubtedly, Medical Technology has improved delivery system effectiveness from the standpoint of decreased mortality and longevity.  But it comes at a substantial cost that ultimately impacts the cost of healthcare delivery.

The cost that society bears for increased longevity gained through technology is substantial, and we know that much of this cost is centered in the world of senior housing, aging services and post-acute/long-term care.  Evidence of the costs associated with chronic disease were explored on Tuesday at the second event of a three-part series being presented by the Alliance for Health Reform in Washington, DC.  Speakers at the event, Health Care Costs: The Role of Technology and Chronic Conditions, shared with participants some very interesting data and analysis (I encourage you to view the slide presentations).

I wish I could have participated because the presentation materials, though very informative, on balance seemed to focus more on general trends in how chronic disease drives healthcare costs rather than focusing on the specific role that Medical Technology has played.  But it nonetheless affords the opportunity to offer some thoughts on technology and the costs of managing and treating chronic disease. 

As the demographic Age Wave continues to move ashore – and taking with it an increasing amount of available resources – the theoretical discussion of tradeoffs between investments in technology and direct caregiving is likely to be become more intense.  Applying the concept of value to that discussion should not be viewed as a subjective assessment of the worth of an extra year, an extra month – an extra day of longevity by virtue of technology.  Rather, it should be viewed as a means of evaluating alternative investments of available resources.  This would seem to be a prudent basis for developing future policy surrounding public investments in technology.

Policy aside, however, senior housing and care providers face a daunting reality with respect to technology: the investment requirements can be substantial – and the consequences of making poor investments difficult from which to operationally and financially recover.  Yet to play in a world of integrated care delivery where both Information and Medical Technology provide distinct competitive advantages, ignoring required investments is just as sure a path to quiet obsolescence.

And while providers wrestle with that two-headed dragon, legislators have not yet appropriately recognized the need for parity investment in PA/LTC technology infrastructure, so many organizations are having to do what they can with available resources to position their technology investments in what they believe (hope) will be in alignment with acute care providers.  The irony here is of course thick if not beyond frustrating because the train that is integrated care delivery has left the station without the cars behind that represent the ability to achieve interoperability with PA/LTC providers.

There is also, I believe, a need of both providers – and policymakers – to understand that technology will only be able to help us so much.  It is not the silver bullet that will save us from the need to become more efficient, streamline care continuums, dramatically improve provider communication and tear down delivery setting silos.  In addition, technology may help encourage but it cannot directly change individual behaviors that could go a long way to curbing chronic disease incidence.

I would really like to better understand how different organizations are addressing their technology strategy.  Is it still a wait and watch situation? Is the need to develop EHR/EMR technology enough to deal with right now? What concerns you the most about technology? Who is involved in that thought process?

Please take a moment to share your input – don’t be afraid to be first . . . somebody has to.  Hot smile

  ~ Sparky




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