Can you comment on your experience with the utilization of physicians extenders, the development of evaluation/treatment protocol and the efficiency issues around this model?
Thank you, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Our research strongly supports the use of physician extenders who are capable of handling the increasing load of rules-based work that no longer requires the expertise of highly-trained physicians. Sophisticated technologies, particularly in the field of diagnostics, have made some parts of medical care so simple to use and interpret, that it makes sense to offload that work to others (even patients themselves). There are a few striking examples of the efficiency improvements made possible by such disruptive technology. For example, Brent James of Intermountain Health Care points to a model where only 3 endocrinologists are able to manage a group of 35,000 diabetic patients. MinuteClinic and other retail clinics enable nurses to perform some of the work that physicians used to do by equipping them with diagnostic technology, sophisticated information systems, and simple algorithms for treatment.
However, there are obstacles faced by such disruptive business models. First, anytime there is an attempt to shift work from experts to non-experts, there are typically concerns about quality. Yet we find that such complaints most often come from incumbent players who feel particularly threatened by new entrants into their industry. We try to present such disruptions as opportunities for incumbents to offload tedious and mundane work in order to focus on the challenging problems which actually require their training and expertise. Nevertheless, the data on quality, performance, and other critical measures have consistently been superior in those models which utilize physician extenders, despite the vocal challenges from incumbents.
Alas, the administered reimbursement system continues to incent physicians to hold onto this work in order to maintain their income. In essence, it "traps" our healthcare system in place and dramatically slows or even halts innovation in many cases. Additional regulations, such as requiring physician oversight (often at defined ratios) or requiring medical licensure in order to write basic prescriptions, further prevent the offloading of work to physician extenders.
You seem to have keen insights into health care epistemology. In your opinion, how might we break monopolies of professional knowledge in health care? How can we push the application of medicine down to the most appropriate skill level, that is, the lowest-skill set that can deliver quality care?
Thank you, in advance, for sharing your thoughts.
Benjamin D. Atkinson
President
Independence Health Center
How do you think we could leverage patient experiences toward determining treatment efficacy? Do you ahve any ideas about how we might collect patient feedback to inform us about treatments?
Any thoughts would be appreciated.
Thanks, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Do you see opportunities in a system that facilitates the conversion of the physician's tacit knowledge into rules-based care, administered by physician extenders?
What, in your opinion, might be the effect on medical practice? Efficiency? Efficacy?
Thanks, in advance, for sharing your ideas.
Benjamin D. Atkinson
President
Independence Health Center
It was difficult to tell whether the software is truly innovative from the entry as it stands now. The website links that you've provided were not easy to access. Therefore, we would like to get more information from you describing the tool’s function, logic, and advantage over existing electronic medical records with decision-making functionality.
Thank you for the questions. Allow me an attempt to make this innovation more perspicuous. I will try to frame my explanation in the parlance of disruptive innovations, as developed by Clayton Christensen.
Because the U.S. healthcare system is physician-centric, I will examine the market through a lens that focuses on jobs that physicians need to get done. This focus may overlook many of the benefits that would accrue to patients and payers, but for simplicity, I will comment on these another time.
Cost pressures are driving physicians toward greater efficiency. Physician extenders can increase practice efficiency. However, many physicians do not utilize extenders effectively, or at all. The most common reason is lack of effective oversight. Common complaints are: "I end up having to watch over the PA's shoulder." Or, "I don't have time to explain to the NP what I want done."
From my research on physician practices, I identified 2 jobs that physicians need to get done:
#1 - I need to know that my physician extenders are doing what I want them to do.
In order to do this job, we can't turn to decision support tools, as they exist today. These tools are typically based on broad recommendations for a limited set of conditions. Most are based on consensus recommendations from professional/government organizations. These guidelines are usually derived from highly-generalized data from several research studies. Many physicians do not place high value on the generic guidelines, since they 'paint with a broad brush'. Physicians want extenders to treat their (the physician's) way.
To get this job done, physicians need a system to create a set of specific rules for specific conditions, distribute them to extenders, be automatically notified of anomalous responses and collect outcomes results. This is attempted today, as 'standing orders' or 'treatment protocol', but on a very limited basis because no efficient system exists for managing this information.
QuIP will soon have a Flash interface. Physicians will be able to drag and drop elements to build evaluation and treatment protocol. Simplicity will be the key for physician acceptance.
#2 - I need to know if my intervention works.
There is not much of a public discourse about this problem, but physicians know that they lack good information about how effective their interventions are. John Wennberg has brought to light the fact that there exists a lot of unnecessary variation. We can assume that part of this variation may be attributed to lack of knowledge about outcomes.
In some ways, evidence-based medicine (EBM) has over-shot the needs of many 'customers'. EBM holds the randomized-control trial as the 'gold standard' of scientific evidence. Statistically, it is unparalleled. However, we know that it takes about 17 years for the 'best evidence' to become clinical practice. Employing a system to distribute care instructions, and collect outcomes at each clinical encounter, brings us a 'good enough' solution.
Assuming that several providers use such a system, sufficient data will be collected to provide useful longitudinal analyses of episodes of care. I include a hypothetical example below:
Imagine that a physiatrist (specialist in Physical Medicine) achieves consistently good outcomes with non-surgical interventions for knee injuries in elite athletes. She has used her specialized knowledge to deduce what works, when and for whom. She knows how to diagnose these conditions and distinguish between patients with good prognoses, and likely candidates for surgical referral. Having applied her rational and empirical powers to the problem, she can now transfer the salient information to a less-skilled provider, via a set of rules.
The physiatrist creates web-based evaluation and treatment protocols for this specific injury via QuIP. The 3 Licensed Athletic Trainers in her clinic can now access the protocols via QuIP, and begin applying them to patients who present with knee injuries. Following the evaluation and treatment protocols, the trainers are able to determine which patients to treat under the protocol and which patients must be referred to the physician. Since the trainers are collecting outcomes at each clinical encounter, the physiatrist is able to monitor the patients’ progress remotely. Automated notifications prompt the physician for review or referral.
After many patients have been treated under this protocol, the physiatrist runs an analysis on this patient population. She finds that most patients progress very well, except a sub-population of perimenopausal marathoners. Made aware of this anomaly, she revises the protocols to address the needs of the middle-aged, female runners. In several months, she is rewarded with improved results for this patient population.
After collecting more results, the physiatrist begins to recognize an opportunity. With collaboration from her trainers, the physiatrist is able to develop a rehabilitation regimen that consists of a simple orthotic device, a self-administered exercise program and 4 weeks of oral medication. A patient is seen by the trainers for 2 weeks, and if progress is good the patient can begin this self-care program. The regimen achieves optimum results in about 8 weeks.
This hypothetical example shows how the transfer of knowledge improves quality, enables innovation and increases productivity in a clinical setting. As more providers us a system like QuIP, all sorts of opportunities emerge around efficacy, as well as efficiency.
I hope this helps elucidate the possibilities of the QuIP platform.
Please contact me with additional questions or comments.
Thank you.
Benjamin D. Atkinson
President
Independence Health Center
Medical knowledge is monopolized by a dispersed and relatively insular group of professionals. Physicians have little incentive or ability to share their outcomes. I have proposed a method for enabling such sharing of information. However, I would be very grateful to hear other ideas for improving the transfer of medical knowledge from the other Change Makers out there.
Thanks, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Dear Mr. Atkinson,
Sharing knowledge is a major part of our WelCare Program. We recognize that our underserved population has a limited interface with major medical providers here. When they need care - they will go to emergency clinics or the emergency room.
In our WelCare program we are being very proactive about bringing medical knowledge to them:
Community Outreach Street Screening seems to have most direct impact on the community. This outreach, which is unduplicated in Galveston County serves several purposes:
It saves lives in an underserved community where there are disparities in health care. Street outreach staff routinely test clients on street corners and have to literally call 9-11 for an ambulance.
It provides referrals for additional services. Clients who appreciate and understand that St. Vincent’s House cares enough to help them in the streets begin to come to the Free Clinic for additional services. Many of those with high blood pressure and diabetes are able to come and get the required medications.
Special populations are encouraged to seek more consistent medical care. For example women who test unfavorably, are encouraged to come to our Women’s Wellness Clinic for a Well Woman check-up, etc;
It provides opportunities to send clients to other providers. By making that outreach staff is able to point clients to additional food sources, homeless providers, substance abuse recovery services and other services not available at St. Vincent’s House.
It encourages other providers and collaborators in the community continuum of care to try more aggressive and innovative approaches to social services.
Our Well-in-Twelve Calender which provides direct nutrition and medical information to clients. We literally provide them with the "how to" cook and eat healthy. What signs to look for to avoid heart attack and stroke, etc;
Our WelCare Classes which provide each client with a WelFolio - a record of their progress in keeping healthy and seeking medical care.
And our MakeOver Series our video series now running on City of Galveston public access television. (You can view several episodes on YouTube - type in "baldiloxx". Our Matt Stanford of our WelCare project is a native of Galveston. He has developed a character "Polish" which is a culturally comfortable model that entertains and informs. The videos are "short plays" teaching our population about diabetes, hypertension, healthy eating, etc;.
In short we view the sharing of positive medical and holistic knowledge as extremely vital to our program. We feel we are proactively intervening in the cycle of poverty and premature death here by actively engaging our underserved population in healthy living patterns.
I hope I'm helping to answer your question.
Please feel free to ask for clarification if I didn't.
Thank you.
Marsha Wilson Rappaport
Director of Grants Management and Development
St. Vincent's House - Galveston, Texas
Thank you for contacting me. I found both your innovation and website very interesting. “Keeping active people active” is inline with the work I do as an occupational therapist. I am definitely in favor of putting knowledge and awareness in the laps of consumers. In response to your E-mail regarding the lack of information sharing, there could be many different reasons for this to happen from not establishing a common lingo among professionals to the want for control, fame, or to make a profit. In your physician-centric model I would be considered an extender. I am in agreement with protocols developed from an interdisciplinary approach where all disciplines bring forth their expertise in problem-solving and creating new interventions. The internet and mobile technology are complementary. Helping consumers to be independent functional thinkers encompasses self-care and more. I think your innovation has great potential it could be something I would subscribe to depending on the cost. Good luck in your endeavors. – Ralph
I see your entry and mine as sharing a common perspective on the problem of health care access, affordability and quality.
Technology has clearly made remote diagnosis successful, affordable and accurate. I note with interest Dr. Hwang's comment about this.
As Hwang also remarks, traditional medical practice resists innovation. Nevertheless, technology must continue to address and then solve the problem of health care delivery to everyone.
Your platform, loaded into the delivery system already in place for all our endless electronic devices that access the web---cell phones, computers, Ipods etc.--accompanied by "insurance" sold at the point of sale for physician extender diagnosis of chronic or intermittent conditions---would immediately insure millions of people worldwide.
Gates/Jobs, etc. and others---Buffet, etc. could spend some money integrating health diagnostic software such as yours into an electronic health package that included the telehealth technology of blood pressure, blood sugar, body temperature, etc. etc.
In a step probably no more complicated than it is now to set up one's cell phone, one could put in the health insurance info, transmit over the web ones results, hear by text message whether one needed to consult a physician for in-person treatment or simply go to the nearby pharmacy for a prescription.
Volume generates sufficient resources to staff remote telehealth "physician extender" call centers in places where medical education is outstanding but salaries are not exhorbitant as they have become in the US, for example India, Cuba etc. where health outcomes are better than the US...and suddenly health insurance, health care and maintenance of chronic health conditions becomes affordable.
This process sorts out the huge volume of people so that care delivery is more rational and efficient.
I should think someone with sufficient resources such as Bill Gates or William Buffet could focus on this system and perfect it rather quickly. Once implemented, innovation would move rapidly to address unforseen consequences, problems.
I think our health care "crisis" is a crisis of imagination. I want to commend your entry for moving us past some of the mental blocks we share. It is especially interesting that other comments indicate the success of small pieces of this new "system" but what is still to come is implementing the system in a way that delivers it to large numbers of people.
Most people who are ill get better with aspirin. Most illnesses are not life threatening. These Doctor visits waste the time and effort of many health professionals every day. Tests on a home computer/health package would give rapid comfort to people worried about their sore throats and fevers and allow severely ill people to get treatment.
Thank you for your entry and for emailing me to bring it to my attention. I certainly hope this system we see only in outline will become a reality for all of us!
Saludos,
Janet W. Youngblood
Thank you for your comments, and for sharing your vision. I do believe that the healthcare struggle will be won, not in the political or professional trenches, but upon the battlefield of epistemology. Technology is tearing down the walls of the towers of knowledge. With the walls go many of the inefficiencies, inequities and inefficacious nostrums that are endemic to healthcare, today.
While an imperfect analogy, I cannot help but compare today's healthcare industry with The Big 3 automakers in the 70's. When confronted with Toyota's innovation they countered with political maneuvers and retreated upstream to their higher margin products. When confronted with pricing pressures, the medical industry has retreated upstream, as well. Generalists are in short supply and we have an excess of specialists, pills are delivered more often than education/coaching, patient autonomy is replaced with crutches.
Attempts at healthcare innovation are met with professional attack. Witness the recent breast-beating by the AMA over retail medical kiosks, or the florid expressions of neurologists when Neurometrix brought their product to market. The increase in medical tourism is actually the importing of healthcare, just like Toyota in the 70's. We haven't learned from these mistakes.
We will all have to unlock our imaginations and break some shackles to turn the healthcare system around. It won't be easy, but I'm seeing more innovative minds working for solutions. Competitions, such as Change Makers, are giving me hope that we'll soon reach a critical mass of committed and imaginative people.
Keep up the good work!
Benjamin D. Atkinson
President
Independence Health Center
Christopher GrayThis proposal may have the seeds of something very intriguing. But, I'm not entirely convinced. First, physician-centric is suggested as a root problem for our medical care system. I am inclined to believe that insurance companies and pressures from HMOs are at least as significant if not more significant. If this system puts physicians behind the computer monitor to devise regimens of their own, how is this really going to help patients?
My greatest concern is the idea of the extenders. We already see the Extender idea utilized by HMOs and hospitals in the United States. What we learn most from this trend is that there is no substitute for knowledge, something an awful lot of Extenders just don't possess. Given this lack of knowledge by Extenders, along with the deplorable state of knowledge of the general public about medical matters, I'm unconvinced that an AI system that dispenses potential treatments, in and of itself, will accomplish what is wanted here.
What this proposal does address that is extremely important however is finding ways to losen the log jam that prevents any kind of diagnosis for sick people.
Thank you for your comments. You raise valid points and I will try to make our approach more perspicuous.
I do not oppose the physician-centric practice of medicine. I do oppose the monopoly of medical knowledge.
I believe the knowledge of the physician is very valuable. It takes many years of education and experience to achieve competence in medicine. However, this value is stifled when it remains locked-up in the mind of the physician. By transferring this tacit knowledge to explicit rules for paradigmatic conditions, we increase the value of this knowledge.
When medical knowledge is distributed to physician extenders (for relatively simple conditions) we increase the value the patient receives. Patients with simpler conditions can receive quality care (usually with shorter waits and lower costs). More of the physician's time is available for patients with more complex conditions, providing better care for the sicker folks.
This is how I see our system helping patients:
More convenient and less costly care for routine medical issues
More time and personal attention for the more serious conditions
And....
If physicians create protocol for routine care, feedback can be collected at each clinical encounter. Now the physician can "know" the effectiveness of their treatment protocol. If these protocol are shared across physicians we may see a "crowd-sourcing" of treatment protocol. I would expect relatively rapid improvements in the effectiveness of routine care.
As technology marches on, more of the complex care will be able to be delivered by extenders. This is the goal of innovation. There have been barriers to innovation in healthcare for a long time, but pockets of innovation exist. I can think of a few innovations that have moved care along the healthcare innovation spectrum: Specialist to Generalist to Extender to Self-care.
Pregnancy tests: These use to be performed in the medical office and now can be performed at home.
Glucometers: Diabetics are now able to monitor their blood chemistry anywhere/anytime.
Neurometrix: I can now test peripheral nerve function anywhere/anytime, with accuracy that rivals a more invasive test performed by a neurologist.
We need to foster innovation in healthcare and I'm convinced that enabling transfers of knowledge will improve care for patients and costs for payers.
Thank you, again, for taking time to review my entry and offer your thoughtful insights.
Benjamin D. Atkinson
President
Independence Health Center
A group of professionals, thoroughly steeped in Clayton Christensen's theories of innovation, recently provided me with feedback about my entry. I thought I would share these insights with the group at large and solicit additional thoughts.
QuIP enables physicians to convert their tacit knowledge into rules-based care. The resultant algorithms may be electronically distributed to non-physician clinicians and community health workers. These 'extenders' may now provide care in more convenient contexts. QuIP also collects outcomes at each clinical encounter to enrich the medical knowledge base and share it with providers, to continuously improve treatments.
Considering strategies to market QuIP, I was focusing on single-physician practices and community health clinics. These entities need the efficiencies that a QuIP-like system can deliver. My innovation-minded colleagues changed my mind about the target markets.
The convoluted US healthcare system, replete with bureaucracy, stifling scope of practice laws and endless flavors of IT make a strong case for bringing a 'good enough' solution to developing countries. Community health workers (the barefoot paramedics) in China and Africa may be better able to utilize a system like QuIP. Cell phone technology would allow these rural providers to carry many evaluation and treatment protocols with them. The feedback collected at the point of care could provide valuable public health info and be used to continuously improve (refine) treatment protocol.
A group, such as Doctors without Borders, could extend their reach through the developing world and increase the quality of care with each clinical encounter. Rapid dissemination of healthcare knowledge through an extender network would dramatically increase access to the 'best' care for people around the world.
From the business side, such an approach would allow QuIP to develop outside of the intense competition in the US market. Steadily growing the number of conditions that can be treated and the database of outcomes, would give the QuIP enterprise a head start when moving upmarket.
I believe this conforms to the classic disruption strategy that Prof. Christensen expounds. I would appreciate any thoughts that you Change Makers might have about such an approach.
Respectfully,
Benjamin D. Atkinson
President
Independence Health Center
I found your Change Maker entry intriguing. Applications in physician practice management seem evident. Dr. Hwang has pointed out some barriers. I like the innovation but see it as having limited impact. Looking at outcomes and pushing tasks to extenders has as much to do with the personality of the providers as anything else. If a physician does want extenders to do more they can do so without the help of technology and data. QuIP then serves a nitch of providers who both want to empower extenders and are interested in analyzing outcomes. In my experience that group is fairly small.
Providers (especially hospitals) are extremely protective of there health records. In order to advance the use of the system something would need to incent providers to use the system. For instance I could see insurance companies tying payment to use of such a system in order to penalize (or reward) better performing practices. If results where open to public domain there is another problem. I am constantly observing that 2 or more people can see the same data and come to completely opposite logical conclusions. Data alone does not better medicine make.
The potential to increase the quality of care within a single group practice could be staggering. It would however have to compete with EMR applications that can do essentially the same thing. For instance protocols are and can be built into many EMR platforms. To understand the outcome you just need to create a report from the system that tracks the protocols you are looking for. QuIP would need to show that it simplifies this task in an easy to understand way. Which it may.
I see our passions lie is a similar direction. I see hope for the healthcare industry as a convergence of ideas more than a single application. One of which is the need to push the edge of what can be done at lower skilled-lower cost settings while increasing quality of care.
Best of Luck
Aaron Robinson
American Community Health System
Thank you for taking time to comment on my entry. I do see our visions sharing some fundamental themes. I also agree that incentives for physicians are paramount to the adoption of new practice tool.
I see a couple incentives. already in place.
Efficiency:
If I am a physician and I can bill $300 for a relatively simple procedure, and I have 2 qualified extenders reporting to me, would I not be motivated to have the extenders perform this procedure? I could perform twice as many procedures at perhaps half the hourly rate.
Now what if I was an endocrinologist and I supervised 20 extenders? I could have an extremely large patient base, see each patient annually to establish/reviewgoals and still have time for the serious problems. My extenders would be the health maintenance front line.
Of course, this could only happen by leveraging technology to ensure proper evaluations and treatments were being performed by the physician extenders. The ability to recognize anomalous events among many patients can only be accomplished electronically.
Efficacy:
This is where I get a little epistemological.
Doctors don't know if their treatment is going to be effective on each patient. We simply don't collect enough data. So, QuIP includes the 'crowdsourcing' component. Protocols that have been defined can be sorted by efficacy (that is, by whatever outcome result the physician defined). I believe that if the outcome results of several evaluation/treatment protocols were made available for a given disease, physicians would change the way they treat that disease.
We would avoid ranking physicians. That's an issue that has been managed disastrously, so far. We would rank treatment protocol, with the physicians who develop the best protocol receiving kudos. Perhaps, we could create a ChangeMaker-like competition for diabetes, for example. The physician(s) that create the most effective and reproducible treatment (a.k.a. protocol) win(s) $250,000. The competition could be sponsored by the American Diabetes Association.
EMRs are a step in the right direction, but they still allow the monopolization of medical knowledge. I hope to break that monopoly.
Thanks, again.
Best regards,
Benjamin D. Atkinson
President
Independence Health Center
Praxis EMR uses a concept processor to facilitate a physician and her medical assistant to do what this does but it matches with the practitioner's past pattern in part while having drug-drug interactions/contraindications and a knowledge base built in.
A rules based system can turn into more of a top down oppressive approach, no matter how well intended at first. An implict, PCP-focused product might be more apt to be productive in the hands of a PCP and medical assistant. There are case examples of this being so in a positive sense by Praxis and in a negative sense by the VA's VisTA system that is clinical practice guideline driven.
Praxis in its next release will have a baseline and customizable knowledge base. It is fully certified, fully HIPPA compatible....etc.
I have no financial interest in Praxis.
I did help develop the rules and rules engine that the VA has and felt progressively oppressed over time by the VA's system especially as it imposed obsolete Pharmacy driven rules to save them pennies while costing my patients needed access to medicines like ARB's without having to get Pharmacy's permission to practice good medicine.
Charles Beauchamp MD, PhD
See JAMA article 2000 on feedback of rules info to ~250 residents at 12 VA clinic sites
Thank you for pointing me toward these examples. I agree that the approach may be better received in the PCP environment. This aligns with the classic disruption model that Clayton Christensen first defined. The PCP may be a less-demanding consumer of a protocol platform. They are looking to get specific job done: Have my extenders treat the simple stuff, effectively.
I think the really neat opportunity lies in the ability to network the protocols and results of a few hundred or thousand PCP. Wouldn't any PCP be interested in knowing what treatments work best, and on whom?
I'll pull the journal article you cited. Thanks, again, for the information and for taking time to comment.
Best regards,
Benjamin D. Atkinson
President
Independence Health Center
The P4P and physician profiling movement has been poorly-managed, in most instances. I don't see how physician quality ratings can be managed in a way that all stakeholders can get behind. "Quality" ratings bear to much resemblance to a black-list or the Scarlet Letter, so physicians balk. "Quality" measures too often focus on process adherence, instead of outcome results, so patients and other payers question the usefulness of this data. Most of the quality measures overshoot most end-users' needs.
Perhaps we can examine the issue through the disruptive lens. I'll try anyway.
What job do we (the healthcare consumer) need done?
As a patient, I need to know which doctor can take care of my medical problem.
As a health plan, I need to know which doctor can treat my client's medical problem, and do so cost-effectively.
It's easy to see why we would focus on the physicians when examining quality measures. They are, after all, in charge of performing the treatment. But, does that make sense?
There is useful quality and cost information for other industries. Consumer Reports provides information about automobile performance and quality. This information is really only useful at the level of automobile model. It is not very useful for the consumer to compare performance and quality information at the manufacturer level. We're hiring this information to help us pick a car, not a car manufacturer.
Looking at healthcare, we see a parallel. When looking for a doc, I'm not trying to hire a physician with a high quality rating. I want the provider who can treat my frozen shoulder, successfully. I want the doctor who can make this rash go away. As consumers we focus on the condition, not the physician. Yes, we give the physician the benefit of the doubt, if we have a relationship with them. But, many consumers shop for doctors, today (within the constraints of their PPO, usually.)
So, if we focus on conditions, then we need to focus on the medical treatment to get useful quality information. And, there can only be a quality measure if there is some standard. That standard may be just the average efficacy and cost of other providers. Quality measures can only be established for routine care, not for cutting edge medicine. By definition, innovative care is non-standard; therefore, quality standards do not exist.
If routine care is the only care for which we can establish quality measures, then we have only to compare the physicians' medical routines (or rules) to establish useful quality standards. If my doctor's rules for treating my earache work faster, cheaper, better than your doctor's rules, we may be able to assign higher value to my doctor's treatment protocol. (Assuming enough similarities in our condition.) Now, we can avoid labeling the physicians as high or low quality. We need only focus on the treatment protocol.
Some auto manufacturers excel along certain dimensions of automobile performance and quality. Certain physicians excel at treating certain illnesses. But, its the rules used by the physicians that determine their efficacy and efficiency. If a treatment cannot be expressed as a rule, the quality of that treatment cannot be assessed. By expressing, sharing and 'crowd-sourcing' these rules we will begin to dramatically increase efficacy and efficiency.
But first, we have to focus our attention to the right level in the healthcare system. Look for effective rules and you'll find healthcare quality.
I would appreciate any comments or feedback.
Respectfully,
Benjamin D. Atkinson
President
Independence Health Center
You bring up some excellent points about a very complex issue. I'll do my best to respond with what we've found in our own research.
First, I think your suggestion of approaching the problem by addressing the jobs to be done for patients is correct. In many cases, patients indeed hire physicians to diagnose and treat specific conditions. However, there are other times when this is less clear, such as primary/preventive care. Therefore, the job is not always a condition in the traditional sense, but there is perhaps a different categorization altogether.
Your car example is one we use quite often and can illustrate the potential for identifying the different jobs in the health delivery market. As you point out, a car buyer is not evaluating cars based on the manufacturer, nor are they looking for a mid-priced sedan between $15-20K. Instead, if the buyer happens to be a salesman, he may want a car that is conducive for mobile work. Such a car would have a laptop tray, easily accessible electrical outlets, etc. The fact that it's a sedan or available in specific colors is not as relevant to the purchasing decision.
Correctly identifying the job is the key to figuring out what constitutes value to the patient. I think only then can you begin to achieve some of the potential that Michael Porter has written about when it's time to reward value.
In any case, however we choose to categorize the jobs, you are correct in stating that the existing payment model fails to map onto them correctly. The existing system of administered pricing and reimbursement is akin to payment via the time-and-motion studies of mass production factories. This may be appropriate for a business model whose processes are entirely rules-based, but this is clearly not yet the case for much of medical care. Most P4P proposals only seem to exacerbate this tendency to focus on specific rules that may have no bearing on value to the patient. The trick is figuring out how to pay for a process that has many highly interdependent steps.
In the early stages of any industry, the leading companies are almost always vertically integrated. It makes sense to own all the steps of the production process because it's just easier and more effective that way when the process is ill-defined and intuitive in nature. However, as the industry matures, other business models become better suited to deliver the steps that have become more rules-based. In essence, it makes sense to begin outsourcing certain steps to suppliers, manufacturers, distributors, etc., as long as the interface with those other firms are modular and predictable. It's up to each company whether they wish to outsource these steps or keep them in-house. In either case, however, they're judged on the end-product (successfully fulfilling the customer's job) and not the individual steps it takes to get there.
Medical science has progressed in a similar fashion. The integrated steps of providing care have long resided in a physician's brain. However, with physician extenders, decision tools, etc., able to do some of the more rules-based work in a much more efficient manner, it's now the physician's prerogative whether to outsource these steps to others. We would tend to favor offloading that work, but a P4P system that merely pays for specific rules provides the wrong incentives.
Instead, a better compensation model would involve having the patient (ideally with as little 3rd party involvement as possible) paying a fee for a job he wants to do. The physician collects that fee and decides whether it is worth giving a piece of that revenue to an EMR, a billing agency, a physician assistant, etc. Ultimately, the ability to consistently get the job done determines value and increases or decreases compensation in the future. If a particular "subcontractor" is responsible for much of the perceived value, then that firm should rightly demand a higher percentage of the revenue. However, the determination of value is not whether certain rules and steps were followed, but whether the outcomes which are important to the patient were achieved.
Comments
Dear Dr. Hwang,
Can you comment on your experience with the utilization of physicians extenders, the development of evaluation/treatment protocol and the efficiency issues around this model?
Thank you, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Our research strongly supports the use of physician extenders who are capable of handling the increasing load of rules-based work that no longer requires the expertise of highly-trained physicians. Sophisticated technologies, particularly in the field of diagnostics, have made some parts of medical care so simple to use and interpret, that it makes sense to offload that work to others (even patients themselves). There are a few striking examples of the efficiency improvements made possible by such disruptive technology. For example, Brent James of Intermountain Health Care points to a model where only 3 endocrinologists are able to manage a group of 35,000 diabetic patients. MinuteClinic and other retail clinics enable nurses to perform some of the work that physicians used to do by equipping them with diagnostic technology, sophisticated information systems, and simple algorithms for treatment.
However, there are obstacles faced by such disruptive business models. First, anytime there is an attempt to shift work from experts to non-experts, there are typically concerns about quality. Yet we find that such complaints most often come from incumbent players who feel particularly threatened by new entrants into their industry. We try to present such disruptions as opportunities for incumbents to offload tedious and mundane work in order to focus on the challenging problems which actually require their training and expertise. Nevertheless, the data on quality, performance, and other critical measures have consistently been superior in those models which utilize physician extenders, despite the vocal challenges from incumbents.
Alas, the administered reimbursement system continues to incent physicians to hold onto this work in order to maintain their income. In essence, it "traps" our healthcare system in place and dramatically slows or even halts innovation in many cases. Additional regulations, such as requiring physician oversight (often at defined ratios) or requiring medical licensure in order to write basic prescriptions, further prevent the offloading of work to physician extenders.
Dr. Reece,
You seem to have keen insights into health care epistemology. In your opinion, how might we break monopolies of professional knowledge in health care? How can we push the application of medicine down to the most appropriate skill level, that is, the lowest-skill set that can deliver quality care?
Thank you, in advance, for sharing your thoughts.
Benjamin D. Atkinson
President
Independence Health Center
Mr. Neff,
I find your proposed web 2.0 model intriguing.
How do you think we could leverage patient experiences toward determining treatment efficacy? Do you ahve any ideas about how we might collect patient feedback to inform us about treatments?
Any thoughts would be appreciated.
Thanks, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Dear Dr. Melvin,
Do you see opportunities in a system that facilitates the conversion of the physician's tacit knowledge into rules-based care, administered by physician extenders?
What, in your opinion, might be the effect on medical practice? Efficiency? Efficacy?
Thanks, in advance, for sharing your ideas.
Benjamin D. Atkinson
President
Independence Health Center
Dear Mr. Atkinson:
It was difficult to tell whether the software is truly innovative from the entry as it stands now. The website links that you've provided were not easy to access. Therefore, we would like to get more information from you describing the tool’s function, logic, and advantage over existing electronic medical records with decision-making functionality.
We thank you in advance for your response.
Changemakers Team
Dear Ms. Ahn,
Thank you for the questions. Allow me an attempt to make this innovation more perspicuous. I will try to frame my explanation in the parlance of disruptive innovations, as developed by Clayton Christensen.
Because the U.S. healthcare system is physician-centric, I will examine the market through a lens that focuses on jobs that physicians need to get done. This focus may overlook many of the benefits that would accrue to patients and payers, but for simplicity, I will comment on these another time.
Cost pressures are driving physicians toward greater efficiency. Physician extenders can increase practice efficiency. However, many physicians do not utilize extenders effectively, or at all. The most common reason is lack of effective oversight. Common complaints are: "I end up having to watch over the PA's shoulder." Or, "I don't have time to explain to the NP what I want done."
From my research on physician practices, I identified 2 jobs that physicians need to get done:
#1 - I need to know that my physician extenders are doing what I want them to do.
In order to do this job, we can't turn to decision support tools, as they exist today. These tools are typically based on broad recommendations for a limited set of conditions. Most are based on consensus recommendations from professional/government organizations. These guidelines are usually derived from highly-generalized data from several research studies. Many physicians do not place high value on the generic guidelines, since they 'paint with a broad brush'. Physicians want extenders to treat their (the physician's) way.
To get this job done, physicians need a system to create a set of specific rules for specific conditions, distribute them to extenders, be automatically notified of anomalous responses and collect outcomes results. This is attempted today, as 'standing orders' or 'treatment protocol', but on a very limited basis because no efficient system exists for managing this information.
QuIP will soon have a Flash interface. Physicians will be able to drag and drop elements to build evaluation and treatment protocol. Simplicity will be the key for physician acceptance.
#2 - I need to know if my intervention works.
There is not much of a public discourse about this problem, but physicians know that they lack good information about how effective their interventions are. John Wennberg has brought to light the fact that there exists a lot of unnecessary variation. We can assume that part of this variation may be attributed to lack of knowledge about outcomes.
In some ways, evidence-based medicine (EBM) has over-shot the needs of many 'customers'. EBM holds the randomized-control trial as the 'gold standard' of scientific evidence. Statistically, it is unparalleled. However, we know that it takes about 17 years for the 'best evidence' to become clinical practice. Employing a system to distribute care instructions, and collect outcomes at each clinical encounter, brings us a 'good enough' solution.
Assuming that several providers use such a system, sufficient data will be collected to provide useful longitudinal analyses of episodes of care. I include a hypothetical example below:
Imagine that a physiatrist (specialist in Physical Medicine) achieves consistently good outcomes with non-surgical interventions for knee injuries in elite athletes. She has used her specialized knowledge to deduce what works, when and for whom. She knows how to diagnose these conditions and distinguish between patients with good prognoses, and likely candidates for surgical referral. Having applied her rational and empirical powers to the problem, she can now transfer the salient information to a less-skilled provider, via a set of rules.
The physiatrist creates web-based evaluation and treatment protocols for this specific injury via QuIP. The 3 Licensed Athletic Trainers in her clinic can now access the protocols via QuIP, and begin applying them to patients who present with knee injuries. Following the evaluation and treatment protocols, the trainers are able to determine which patients to treat under the protocol and which patients must be referred to the physician. Since the trainers are collecting outcomes at each clinical encounter, the physiatrist is able to monitor the patients’ progress remotely. Automated notifications prompt the physician for review or referral.
After many patients have been treated under this protocol, the physiatrist runs an analysis on this patient population. She finds that most patients progress very well, except a sub-population of perimenopausal marathoners. Made aware of this anomaly, she revises the protocols to address the needs of the middle-aged, female runners. In several months, she is rewarded with improved results for this patient population.
After collecting more results, the physiatrist begins to recognize an opportunity. With collaboration from her trainers, the physiatrist is able to develop a rehabilitation regimen that consists of a simple orthotic device, a self-administered exercise program and 4 weeks of oral medication. A patient is seen by the trainers for 2 weeks, and if progress is good the patient can begin this self-care program. The regimen achieves optimum results in about 8 weeks.
This hypothetical example shows how the transfer of knowledge improves quality, enables innovation and increases productivity in a clinical setting. As more providers us a system like QuIP, all sorts of opportunities emerge around efficacy, as well as efficiency.
I hope this helps elucidate the possibilities of the QuIP platform.
Please contact me with additional questions or comments.
Thank you.
Benjamin D. Atkinson
President
Independence Health Center
A paradox:
Medical knowledge is monopolized by a dispersed and relatively insular group of professionals. Physicians have little incentive or ability to share their outcomes. I have proposed a method for enabling such sharing of information. However, I would be very grateful to hear other ideas for improving the transfer of medical knowledge from the other Change Makers out there.
Thanks, in advance.
Benjamin D. Atkinson
President
Independence Health Center
Dear Mr. Atkinson,
Sharing knowledge is a major part of our WelCare Program. We recognize that our underserved population has a limited interface with major medical providers here. When they need care - they will go to emergency clinics or the emergency room.
In our WelCare program we are being very proactive about bringing medical knowledge to them:
Community Outreach Street Screening seems to have most direct impact on the community. This outreach, which is unduplicated in Galveston County serves several purposes:
It saves lives in an underserved community where there are disparities in health care. Street outreach staff routinely test clients on street corners and have to literally call 9-11 for an ambulance.
It provides referrals for additional services. Clients who appreciate and understand that St. Vincent’s House cares enough to help them in the streets begin to come to the Free Clinic for additional services. Many of those with high blood pressure and diabetes are able to come and get the required medications.
Special populations are encouraged to seek more consistent medical care. For example women who test unfavorably, are encouraged to come to our Women’s Wellness Clinic for a Well Woman check-up, etc;
It provides opportunities to send clients to other providers. By making that outreach staff is able to point clients to additional food sources, homeless providers, substance abuse recovery services and other services not available at St. Vincent’s House.
It encourages other providers and collaborators in the community continuum of care to try more aggressive and innovative approaches to social services.
Our Well-in-Twelve Calender which provides direct nutrition and medical information to clients. We literally provide them with the "how to" cook and eat healthy. What signs to look for to avoid heart attack and stroke, etc;
Our WelCare Classes which provide each client with a WelFolio - a record of their progress in keeping healthy and seeking medical care.
And our MakeOver Series our video series now running on City of Galveston public access television. (You can view several episodes on YouTube - type in "baldiloxx". Our Matt Stanford of our WelCare project is a native of Galveston. He has developed a character "Polish" which is a culturally comfortable model that entertains and informs. The videos are "short plays" teaching our population about diabetes, hypertension, healthy eating, etc;.
In short we view the sharing of positive medical and holistic knowledge as extremely vital to our program. We feel we are proactively intervening in the cycle of poverty and premature death here by actively engaging our underserved population in healthy living patterns.
I hope I'm helping to answer your question.
Please feel free to ask for clarification if I didn't.
Thank you.
Marsha Wilson Rappaport
Director of Grants Management and Development
St. Vincent's House - Galveston, Texas
Thank you for contacting me. I found both your innovation and website very interesting. “Keeping active people active” is inline with the work I do as an occupational therapist. I am definitely in favor of putting knowledge and awareness in the laps of consumers. In response to your E-mail regarding the lack of information sharing, there could be many different reasons for this to happen from not establishing a common lingo among professionals to the want for control, fame, or to make a profit. In your physician-centric model I would be considered an extender. I am in agreement with protocols developed from an interdisciplinary approach where all disciplines bring forth their expertise in problem-solving and creating new interventions. The internet and mobile technology are complementary. Helping consumers to be independent functional thinkers encompasses self-care and more. I think your innovation has great potential it could be something I would subscribe to depending on the cost. Good luck in your endeavors. – Ralph
Janet W. Youngblood, MA, MBA, Ed.D.
Dear Dr. Atkinson:
I see your entry and mine as sharing a common perspective on the problem of health care access, affordability and quality.
Technology has clearly made remote diagnosis successful, affordable and accurate. I note with interest Dr. Hwang's comment about this.
As Hwang also remarks, traditional medical practice resists innovation. Nevertheless, technology must continue to address and then solve the problem of health care delivery to everyone.
Your platform, loaded into the delivery system already in place for all our endless electronic devices that access the web---cell phones, computers, Ipods etc.--accompanied by "insurance" sold at the point of sale for physician extender diagnosis of chronic or intermittent conditions---would immediately insure millions of people worldwide.
Gates/Jobs, etc. and others---Buffet, etc. could spend some money integrating health diagnostic software such as yours into an electronic health package that included the telehealth technology of blood pressure, blood sugar, body temperature, etc. etc.
In a step probably no more complicated than it is now to set up one's cell phone, one could put in the health insurance info, transmit over the web ones results, hear by text message whether one needed to consult a physician for in-person treatment or simply go to the nearby pharmacy for a prescription.
Volume generates sufficient resources to staff remote telehealth "physician extender" call centers in places where medical education is outstanding but salaries are not exhorbitant as they have become in the US, for example India, Cuba etc. where health outcomes are better than the US...and suddenly health insurance, health care and maintenance of chronic health conditions becomes affordable.
This process sorts out the huge volume of people so that care delivery is more rational and efficient.
I should think someone with sufficient resources such as Bill Gates or William Buffet could focus on this system and perfect it rather quickly. Once implemented, innovation would move rapidly to address unforseen consequences, problems.
I think our health care "crisis" is a crisis of imagination. I want to commend your entry for moving us past some of the mental blocks we share. It is especially interesting that other comments indicate the success of small pieces of this new "system" but what is still to come is implementing the system in a way that delivers it to large numbers of people.
Most people who are ill get better with aspirin. Most illnesses are not life threatening. These Doctor visits waste the time and effort of many health professionals every day. Tests on a home computer/health package would give rapid comfort to people worried about their sore throats and fevers and allow severely ill people to get treatment.
Thank you for your entry and for emailing me to bring it to my attention. I certainly hope this system we see only in outline will become a reality for all of us!
Saludos,
Janet W. Youngblood
Ms. Youngblood,
Thank you for your comments, and for sharing your vision. I do believe that the healthcare struggle will be won, not in the political or professional trenches, but upon the battlefield of epistemology. Technology is tearing down the walls of the towers of knowledge. With the walls go many of the inefficiencies, inequities and inefficacious nostrums that are endemic to healthcare, today.
While an imperfect analogy, I cannot help but compare today's healthcare industry with The Big 3 automakers in the 70's. When confronted with Toyota's innovation they countered with political maneuvers and retreated upstream to their higher margin products. When confronted with pricing pressures, the medical industry has retreated upstream, as well. Generalists are in short supply and we have an excess of specialists, pills are delivered more often than education/coaching, patient autonomy is replaced with crutches.
Attempts at healthcare innovation are met with professional attack. Witness the recent breast-beating by the AMA over retail medical kiosks, or the florid expressions of neurologists when Neurometrix brought their product to market. The increase in medical tourism is actually the importing of healthcare, just like Toyota in the 70's. We haven't learned from these mistakes.
We will all have to unlock our imaginations and break some shackles to turn the healthcare system around. It won't be easy, but I'm seeing more innovative minds working for solutions. Competitions, such as Change Makers, are giving me hope that we'll soon reach a critical mass of committed and imaginative people.
Keep up the good work!
Benjamin D. Atkinson
President
Independence Health Center
Christopher GrayThis proposal may have the seeds of something very intriguing. But, I'm not entirely convinced. First, physician-centric is suggested as a root problem for our medical care system. I am inclined to believe that insurance companies and pressures from HMOs are at least as significant if not more significant. If this system puts physicians behind the computer monitor to devise regimens of their own, how is this really going to help patients?
My greatest concern is the idea of the extenders. We already see the Extender idea utilized by HMOs and hospitals in the United States. What we learn most from this trend is that there is no substitute for knowledge, something an awful lot of Extenders just don't possess. Given this lack of knowledge by Extenders, along with the deplorable state of knowledge of the general public about medical matters, I'm unconvinced that an AI system that dispenses potential treatments, in and of itself, will accomplish what is wanted here.
What this proposal does address that is extremely important however is finding ways to losen the log jam that prevents any kind of diagnosis for sick people.
Thank you.
Dear Mr. Gray,
Thank you for your comments. You raise valid points and I will try to make our approach more perspicuous.
I do not oppose the physician-centric practice of medicine. I do oppose the monopoly of medical knowledge.
I believe the knowledge of the physician is very valuable. It takes many years of education and experience to achieve competence in medicine. However, this value is stifled when it remains locked-up in the mind of the physician. By transferring this tacit knowledge to explicit rules for paradigmatic conditions, we increase the value of this knowledge.
When medical knowledge is distributed to physician extenders (for relatively simple conditions) we increase the value the patient receives. Patients with simpler conditions can receive quality care (usually with shorter waits and lower costs). More of the physician's time is available for patients with more complex conditions, providing better care for the sicker folks.
This is how I see our system helping patients:
And....
If physicians create protocol for routine care, feedback can be collected at each clinical encounter. Now the physician can "know" the effectiveness of their treatment protocol. If these protocol are shared across physicians we may see a "crowd-sourcing" of treatment protocol. I would expect relatively rapid improvements in the effectiveness of routine care.
As technology marches on, more of the complex care will be able to be delivered by extenders. This is the goal of innovation. There have been barriers to innovation in healthcare for a long time, but pockets of innovation exist. I can think of a few innovations that have moved care along the healthcare innovation spectrum: Specialist to Generalist to Extender to Self-care.
We need to foster innovation in healthcare and I'm convinced that enabling transfers of knowledge will improve care for patients and costs for payers.
Thank you, again, for taking time to review my entry and offer your thoughtful insights.
Benjamin D. Atkinson
President
Independence Health Center
Dear Change Makers,
A group of professionals, thoroughly steeped in Clayton Christensen's theories of innovation, recently provided me with feedback about my entry. I thought I would share these insights with the group at large and solicit additional thoughts.
QuIP enables physicians to convert their tacit knowledge into rules-based care. The resultant algorithms may be electronically distributed to non-physician clinicians and community health workers. These 'extenders' may now provide care in more convenient contexts. QuIP also collects outcomes at each clinical encounter to enrich the medical knowledge base and share it with providers, to continuously improve treatments.
Considering strategies to market QuIP, I was focusing on single-physician practices and community health clinics. These entities need the efficiencies that a QuIP-like system can deliver. My innovation-minded colleagues changed my mind about the target markets.
The convoluted US healthcare system, replete with bureaucracy, stifling scope of practice laws and endless flavors of IT make a strong case for bringing a 'good enough' solution to developing countries. Community health workers (the barefoot paramedics) in China and Africa may be better able to utilize a system like QuIP. Cell phone technology would allow these rural providers to carry many evaluation and treatment protocols with them. The feedback collected at the point of care could provide valuable public health info and be used to continuously improve (refine) treatment protocol.
A group, such as Doctors without Borders, could extend their reach through the developing world and increase the quality of care with each clinical encounter. Rapid dissemination of healthcare knowledge through an extender network would dramatically increase access to the 'best' care for people around the world.
From the business side, such an approach would allow QuIP to develop outside of the intense competition in the US market. Steadily growing the number of conditions that can be treated and the database of outcomes, would give the QuIP enterprise a head start when moving upmarket.
I believe this conforms to the classic disruption strategy that Prof. Christensen expounds. I would appreciate any thoughts that you Change Makers might have about such an approach.
Respectfully,
Benjamin D. Atkinson
President
Independence Health Center
I found your Change Maker entry intriguing. Applications in physician practice management seem evident. Dr. Hwang has pointed out some barriers. I like the innovation but see it as having limited impact. Looking at outcomes and pushing tasks to extenders has as much to do with the personality of the providers as anything else. If a physician does want extenders to do more they can do so without the help of technology and data. QuIP then serves a nitch of providers who both want to empower extenders and are interested in analyzing outcomes. In my experience that group is fairly small.
Providers (especially hospitals) are extremely protective of there health records. In order to advance the use of the system something would need to incent providers to use the system. For instance I could see insurance companies tying payment to use of such a system in order to penalize (or reward) better performing practices. If results where open to public domain there is another problem. I am constantly observing that 2 or more people can see the same data and come to completely opposite logical conclusions. Data alone does not better medicine make.
The potential to increase the quality of care within a single group practice could be staggering. It would however have to compete with EMR applications that can do essentially the same thing. For instance protocols are and can be built into many EMR platforms. To understand the outcome you just need to create a report from the system that tracks the protocols you are looking for. QuIP would need to show that it simplifies this task in an easy to understand way. Which it may.
I see our passions lie is a similar direction. I see hope for the healthcare industry as a convergence of ideas more than a single application. One of which is the need to push the edge of what can be done at lower skilled-lower cost settings while increasing quality of care.
Best of Luck
Aaron Robinson
American Community Health System
Mr. Robinson,
Thank you for taking time to comment on my entry. I do see our visions sharing some fundamental themes. I also agree that incentives for physicians are paramount to the adoption of new practice tool.
I see a couple incentives. already in place.
Efficiency:
If I am a physician and I can bill $300 for a relatively simple procedure, and I have 2 qualified extenders reporting to me, would I not be motivated to have the extenders perform this procedure? I could perform twice as many procedures at perhaps half the hourly rate.
Now what if I was an endocrinologist and I supervised 20 extenders? I could have an extremely large patient base, see each patient annually to establish/reviewgoals and still have time for the serious problems. My extenders would be the health maintenance front line.
Of course, this could only happen by leveraging technology to ensure proper evaluations and treatments were being performed by the physician extenders. The ability to recognize anomalous events among many patients can only be accomplished electronically.
Efficacy:
This is where I get a little epistemological.
Doctors don't know if their treatment is going to be effective on each patient. We simply don't collect enough data. So, QuIP includes the 'crowdsourcing' component. Protocols that have been defined can be sorted by efficacy (that is, by whatever outcome result the physician defined). I believe that if the outcome results of several evaluation/treatment protocols were made available for a given disease, physicians would change the way they treat that disease.
We would avoid ranking physicians. That's an issue that has been managed disastrously, so far. We would rank treatment protocol, with the physicians who develop the best protocol receiving kudos. Perhaps, we could create a ChangeMaker-like competition for diabetes, for example. The physician(s) that create the most effective and reproducible treatment (a.k.a. protocol) win(s) $250,000. The competition could be sponsored by the American Diabetes Association.
EMRs are a step in the right direction, but they still allow the monopolization of medical knowledge. I hope to break that monopoly.
Thanks, again.
Best regards,
Benjamin D. Atkinson
President
Independence Health Center
Praxis EMR uses a concept processor to facilitate a physician and her medical assistant to do what this does but it matches with the practitioner's past pattern in part while having drug-drug interactions/contraindications and a knowledge base built in.
A rules based system can turn into more of a top down oppressive approach, no matter how well intended at first. An implict, PCP-focused product might be more apt to be productive in the hands of a PCP and medical assistant. There are case examples of this being so in a positive sense by Praxis and in a negative sense by the VA's VisTA system that is clinical practice guideline driven.
Praxis in its next release will have a baseline and customizable knowledge base. It is fully certified, fully HIPPA compatible....etc.
I have no financial interest in Praxis.
I did help develop the rules and rules engine that the VA has and felt progressively oppressed over time by the VA's system especially as it imposed obsolete Pharmacy driven rules to save them pennies while costing my patients needed access to medicines like ARB's without having to get Pharmacy's permission to practice good medicine.
Charles Beauchamp MD, PhD
See JAMA article 2000 on feedback of rules info to ~250 residents at 12 VA clinic sites
Dear Dr. Beauchamp,
Thank you for pointing me toward these examples. I agree that the approach may be better received in the PCP environment. This aligns with the classic disruption model that Clayton Christensen first defined. The PCP may be a less-demanding consumer of a protocol platform. They are looking to get specific job done: Have my extenders treat the simple stuff, effectively.
I think the really neat opportunity lies in the ability to network the protocols and results of a few hundred or thousand PCP. Wouldn't any PCP be interested in knowing what treatments work best, and on whom?
I'll pull the journal article you cited. Thanks, again, for the information and for taking time to comment.
Best regards,
Benjamin D. Atkinson
President
Independence Health Center
The P4P and physician profiling movement has been poorly-managed, in most instances. I don't see how physician quality ratings can be managed in a way that all stakeholders can get behind. "Quality" ratings bear to much resemblance to a black-list or the Scarlet Letter, so physicians balk. "Quality" measures too often focus on process adherence, instead of outcome results, so patients and other payers question the usefulness of this data. Most of the quality measures overshoot most end-users' needs.
Perhaps we can examine the issue through the disruptive lens. I'll try anyway.
What job do we (the healthcare consumer) need done?
As a patient, I need to know which doctor can take care of my medical problem.
As a health plan, I need to know which doctor can treat my client's medical problem, and do so cost-effectively.
It's easy to see why we would focus on the physicians when examining quality measures. They are, after all, in charge of performing the treatment. But, does that make sense?
There is useful quality and cost information for other industries. Consumer Reports provides information about automobile performance and quality. This information is really only useful at the level of automobile model. It is not very useful for the consumer to compare performance and quality information at the manufacturer level. We're hiring this information to help us pick a car, not a car manufacturer.
Looking at healthcare, we see a parallel. When looking for a doc, I'm not trying to hire a physician with a high quality rating. I want the provider who can treat my frozen shoulder, successfully. I want the doctor who can make this rash go away. As consumers we focus on the condition, not the physician. Yes, we give the physician the benefit of the doubt, if we have a relationship with them. But, many consumers shop for doctors, today (within the constraints of their PPO, usually.)
So, if we focus on conditions, then we need to focus on the medical treatment to get useful quality information. And, there can only be a quality measure if there is some standard. That standard may be just the average efficacy and cost of other providers. Quality measures can only be established for routine care, not for cutting edge medicine. By definition, innovative care is non-standard; therefore, quality standards do not exist.
If routine care is the only care for which we can establish quality measures, then we have only to compare the physicians' medical routines (or rules) to establish useful quality standards. If my doctor's rules for treating my earache work faster, cheaper, better than your doctor's rules, we may be able to assign higher value to my doctor's treatment protocol. (Assuming enough similarities in our condition.) Now, we can avoid labeling the physicians as high or low quality. We need only focus on the treatment protocol.
Some auto manufacturers excel along certain dimensions of automobile performance and quality. Certain physicians excel at treating certain illnesses. But, its the rules used by the physicians that determine their efficacy and efficiency. If a treatment cannot be expressed as a rule, the quality of that treatment cannot be assessed. By expressing, sharing and 'crowd-sourcing' these rules we will begin to dramatically increase efficacy and efficiency.
But first, we have to focus our attention to the right level in the healthcare system. Look for effective rules and you'll find healthcare quality.
I would appreciate any comments or feedback.
Respectfully,
Benjamin D. Atkinson
President
Independence Health Center
You bring up some excellent points about a very complex issue. I'll do my best to respond with what we've found in our own research.
First, I think your suggestion of approaching the problem by addressing the jobs to be done for patients is correct. In many cases, patients indeed hire physicians to diagnose and treat specific conditions. However, there are other times when this is less clear, such as primary/preventive care. Therefore, the job is not always a condition in the traditional sense, but there is perhaps a different categorization altogether.
Your car example is one we use quite often and can illustrate the potential for identifying the different jobs in the health delivery market. As you point out, a car buyer is not evaluating cars based on the manufacturer, nor are they looking for a mid-priced sedan between $15-20K. Instead, if the buyer happens to be a salesman, he may want a car that is conducive for mobile work. Such a car would have a laptop tray, easily accessible electrical outlets, etc. The fact that it's a sedan or available in specific colors is not as relevant to the purchasing decision.
Correctly identifying the job is the key to figuring out what constitutes value to the patient. I think only then can you begin to achieve some of the potential that Michael Porter has written about when it's time to reward value.
In any case, however we choose to categorize the jobs, you are correct in stating that the existing payment model fails to map onto them correctly. The existing system of administered pricing and reimbursement is akin to payment via the time-and-motion studies of mass production factories. This may be appropriate for a business model whose processes are entirely rules-based, but this is clearly not yet the case for much of medical care. Most P4P proposals only seem to exacerbate this tendency to focus on specific rules that may have no bearing on value to the patient. The trick is figuring out how to pay for a process that has many highly interdependent steps.
In the early stages of any industry, the leading companies are almost always vertically integrated. It makes sense to own all the steps of the production process because it's just easier and more effective that way when the process is ill-defined and intuitive in nature. However, as the industry matures, other business models become better suited to deliver the steps that have become more rules-based. In essence, it makes sense to begin outsourcing certain steps to suppliers, manufacturers, distributors, etc., as long as the interface with those other firms are modular and predictable. It's up to each company whether they wish to outsource these steps or keep them in-house. In either case, however, they're judged on the end-product (successfully fulfilling the customer's job) and not the individual steps it takes to get there.
Medical science has progressed in a similar fashion. The integrated steps of providing care have long resided in a physician's brain. However, with physician extenders, decision tools, etc., able to do some of the more rules-based work in a much more efficient manner, it's now the physician's prerogative whether to outsource these steps to others. We would tend to favor offloading that work, but a P4P system that merely pays for specific rules provides the wrong incentives.
Instead, a better compensation model would involve having the patient (ideally with as little 3rd party involvement as possible) paying a fee for a job he wants to do. The physician collects that fee and decides whether it is worth giving a piece of that revenue to an EMR, a billing agency, a physician assistant, etc. Ultimately, the ability to consistently get the job done determines value and increases or decreases compensation in the future. If a particular "subcontractor" is responsible for much of the perceived value, then that firm should rightly demand a higher percentage of the revenue. However, the determination of value is not whether certain rules and steps were followed, but whether the outcomes which are important to the patient were achieved.
Benjamin D. Atkinson
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