Something Wizard This Way Comes

Joe Flower

The country seems to have shifted in less than 18 months from a slogan of “Yes We Can!” to “Oh, well…” and a shrug, then back to “Cool! I think. What was that, really?” Hopes for a true rebirth of health care turned into the Year of Screaming Inanely, then took that long slide from what we might hope for to what we might settle for. Yet suddenly it seems like things are popping up all over the place, like mushrooms on a forest floor in springtime. New projects and initiatives are emerging from little companies, big companies, garage startups, info-giants and mega-industrial combines.

It looks just as if, frustrated by a glacial and refractory legislative process, Americans and American companies have taken matters into their own hands, not with torches and pitchforks, but devices and codes and business models, all trying to figure out some way they can help make health care better, faster and cheaper. It is as if Rosie the Riveter of the World War II poster were once again flexing a muscle and saying, “We can do it!”

Better for Less

“Better, faster and cheaper?” The glib management saw is: “Quality, cost and speed—choose two.” The received wisdom is that you can do things at high quality and low cost, but it will take a long time. If you want high quality at high speed, it will cost a bundle. If you want low cost and high speed, you can’t have quality.

But health care does not fit that wisdom at all. In health care “speed” translates to “accessibility,” in terms of coverage, availability of services and convenience, as well as sheer rapid response.

And uniquely in health care, the management saw is wrong: You can have all three. The Dartmouth Center studies repeatedly show that efficiency and effectiveness go together in health care. There is no clinical advantage to making the process more clunky, difficult and expensive. And more is not better in health care—doing more tests and more procedures actually correlates not just with added cost, but with worse outcomes. Efficiency, convenience and low cost are therapeutically effective.

This is the giant prize at the center of the labyrinth of changing health care: We could do it better for less. Much better, for much less. And more and more companies are heading straight for that prize.

Retail Clinics

Let me give you a few examples. They sometimes are big, bold actions, and sometimes are things that seem like details from the outside, but could turn out to be very large.

CVS/Caremark, for instance. The CVS pharmacy chain has been growing very quickly over the last 15 years, swallowing up Revco, Arbor, Eckard, Sav-On, Osco and Longs, ballooning from 1,400 stores to over 7,000. In 2006, it bought MinuteClinic, a chain of retail clinics, and began expanding it to almost 600 locations today. In 2007, CVS merged with the massive pharmacy benefit manager Caremark, with some 64,000 participating pharmacies, to become CVS/Caremark. The combined organization is now the largest provider of prescription medicines in the nation.

The interesting detail? CVS/Caremark has decided to use its massive market footprint to do something about chronic disease, starting with diabetes. It goes beyond the more usual passive education programs to aggressively get out and work with patients by, for instance, sending a nurse to your house to show you how to test your glucose level, how to use insulin and how to regulate your diet to keep the disease in check.

And the PBM side of the company is working with the pharmacy part so you can walk into any MinuteClinic to get the same advice, or get your A1c score tested, any time that is convenient, instead of having to make an appointment at a doctor’s office. There is likely a convincing business model to such services, but these kinds of direct patient services are much harder to pull off than another PBM deal or opening another store. They are the kind of thing a company has to want to do.

A Leader in Efficiency

GE Healthcare, with 46,000 employees, headquartered in the United Kingdom, is one of the largest vendors of medical equipment in the world, owning (to take one example) 80 percent of all the anesthesia machines in the United States and 60 percent of the machines in the world. Like all of General Electric, the world’s largest corporation, GE Healthcare is highly focused on quality, and the processes by which it continually hones its products and abilities.

But GE Healthcare has come to realize that this mindset, so natural within GE, is not shared by its customers, who often think quite differently, and have quite different concerns and incentives. Within the past year, it set out on a major program involving all its major executives, down to the manager level, especially in the service division, which interacts with the customers on-site every day for years on end, to better understand the customer—how the industry works, how it makes its money, how it gets things done, why quality and efficiency in processes are only beginning to be understood across much of health care.

They are doing this, GE executives tell me, not only to work with their customers better, but also partly to influence their customers, to educate them to the way GE thinks about quality and efficiency. I asked one GE Healthcare executive how this would help sales. If it were really able to help its customers be more efficient, wouldn’t they be more efficient, among other things, in using GE machines—and so actually buy fewer units?

“That may happen,” he told me, “but we see that health care simply has to change, and it will change, to be more lean and efficient. If we help lead that charge, we will be identified in the customers’ minds with a whole new way of working more efficiently, with less variation, and better quality.”

New Approaches to Storing Health Records

Personal health records make up one big mushroom patch. Google Health, for instance, provides a place where patients can keep their health records. But here again, the revolutionary force is down in the details. Besides plain old record storage, Google Health also provides what may become a de facto standard for personal health records, making the CCR standard it has adopted into the MP3 of health records.

Equally important, both Microsoft’s HealthVault and Google Health work like Apple’s iPhone: They provide an open platform with an API—an application programming interface—for which anyone can design apps. MDLiveCare, the see-a-real-doctor-online-right-now site I mentioned in a previous column, is an app integrated with Google Health, as OnlineCare is with HealthVault.

Similarly, SalesForce.com has invested in (and provided its Force.com platform for) PracticeFusion, a free medical practice suite. Its ChartShare allows any authorized provider to view and interact with the patient’s chart—and its sibling, PatientFusion, gives the patient a look at the chart arranged in one convenient interface. All of this software is free.

The business models are all over the map. Like many things Google does, Google Health does not really have a business model, except Google’s belief (so far well-founded) that the more it can provide storage and search and interface for every bit of information on the planet, the more it will prosper. Google Health does not plop advertising on your chart, and does not sell your information to anyone. PracticeFusion supports itself through advertising and through selling impersonal, statistical information about disease trends. MDLiveCare asks for your credit card information.

Mostly, these companies seem to be in a kind of land rush. They see health information as a nowhere-near-mature field, and they are staking out the territory with little or no focus on profit for now.
New Platforms

If we want to imagine the true power of these patient interfaces, we have to look even beyond today’s Internet browser-driven information world to the new platforms arising right now: the smart phone and the whatever we will call the generic version of the iPad. The iPhone is not just a product, it is a platform. Though Apple is suing its imitators, the platform will be imitated, copied, expanded and made cheaper. The core of it is not the device, it is the combination of cheap or free apps on a relatively open platform for which anyone can design.

The growth of this model has been explosive: More than 140,000 apps are now available for the iPhone alone; people have downloaded more than 3 billion of them. There is already a website dedicated just to reviewing medical apps (iMedicalApp.com, of course), including patient scheduler apps, charge capture apps, medical calculators and patient trackers.

The recently launched iPad will likely be another platform—similar, but bigger and even easier to use, big enough to share, intuitive enough for the non-tech-savvy, on which anyone can build any app, especially including patient health care interfaces of every flavor. Like the iPhone, it will launch a flood of imitators as well, and manufacturers are already developing medical applications and accessories for it.

Real Value

None of these things will “fix” health care. But collectively they route around its problems and head more directly toward the real value we are looking for—the health of the patient, at the highest possible quality and the least possible cost. Insurance reform can make health care more available for more people. But collectively, these innovations do what insurance reform could never do—actually make health care better, faster, cheaper.

Cartoonist Walt Kelley’s character Pogo famously pronounced: “We have met the enemy and he is us.” But Buddhist teacher Pema Chodron much less famously pointed out that there is a corollary to Pogo’s pronouncement: “I have met the friend and he is me.” In health care we have for a long time been our own worst enemies, each defending our own turf and way of doing things, often caught in a welter of mixed incentives that would cross an investment banker’s eyes. In these disruptive innovations, we can see the million ways we have of becoming our own best friends.

Joe Flower is a healthcare futurist and consultant based in San Francisco. This post first appeared in the May 10, 2010 issue of Hospitals and Health Networks.  You can Learn more about Joe and read his columns at his web site. ImagineWhatIf.com.

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11 replies »

  1. Fantastic website you have here but I was curious about if you knew of any message boards that cover the same topics talked about in this article? I’d really like to be a part of group where I can get responses from other knowledgeable people that share the same interest. If you have any recommendations, please let me know. Cheers!San Francisco Roofing, 1276 7th Ave., San Francisco, CA 94122 – (415) 800-4100

  2. > didn’t Cedars complained about how this stuff is measured
    They may have, I hadn’t heard that. But that’s irrelevant, because 1) everyone always complains about methodology every single time they end up on the wrong end of some study, and I just don’t buy it. Clearly, not all studies are perfect, far from it. But I tend to discount the special pleading the inevitably arises in the face of such studies, especially because 2) There is a pattern here: Some places clearly cost a lot more than other places, and the difference clearly does not map onto differences in quality. The question, “How can the best health care in the world cost twice as much as the best health care in the world?” still stands.

  3. Yes Joe, we should, probably. However, unless we have reached max quality already, a little more money should be able to buy a little more quality. It may not be the case when observing people on their death beds, but in other scenarios it should be feasible, if not through direct care, then maybe through more research, more education, more outreach, etc.
    BTW, didn’t Cedars complained about how this stuff is measured, since their contention was that less folks end up being in their last six months of life due to Cedars more aggressive measures?

  4. Margalit, as always, your heart’s in the right place, but your head – & maybe your guts this time – are not.
    you said:

    I agree that a good, and time honored way of reducing health care costs is to push more care to free resources – patients. However, at what point will we be pushing to much? At what point will those without financial and educational resources be penalized? Homeless folks have very little use for home monitoring devices. Caution would be very advisable.

    The fact is that you won’t know at what point if you don’t push towards that point – that is, if you don’t DO SOMETHING.
    Homeless folks live somewhere – and the utility of mobile health devices has been most concretely identified in places where mud is the go-to mortar, straw the top-grade roofing material.
    Attention to the results of doing something is certainly advisable, generic “caution” is most certainly INadvisable. We’ve been doing caution, & it’s a key contributor to the survival of stagnant if not outright broken models.

  5. > the highest possible quality we can get for $1 will always be smaller than the highest possible quality we can get for $2.
    Not necessarily so. One example: A survey a while back showed that some medical centers cost twice as much to spend the last six months of life than others. Top of the list: Cedars Sinai, L.A. Bottom of the list, at half the cost? Mayo Clinic, Minnesota, slightly cheaper than the Cleveland Clinic. So the best health care in the world costs half as much as the best health care in the world. W. Edwards Deming famously talked about “quality for free,” and nowhere is that more true than in health care. We could do this better, for everyone, for half as much.

  6. I’ll second Margalit’s very well-stated words, with just this minor addition:
    “There is no clinical advantage to making the process more clunky, difficult and expensive.” I don’t believe there’s ever an advantage to make things harder, slower, or costlier, in any project. That management law works like the law of gravity: no one made this law or is enforcing it blindly. Instead, it is a description of what we observe to happen. We observe that, usually, having two high-performing points results in a lesser value in the third, and so advice that such will probably occur.
    However, I do like the quote from the Buddhist teacher. Very zen and possibly true.

  7. Sounds very rosy, Joe, but I’m afraid it also sounds a bit too simple.
    First the famous triad of constraints is not so straight forward because each constraint has a threshold after which the triangle breaks. For example, you can keep accessibility constant and reduce cost without harming quality up to a point. After that point, quality will be harmed. It is possible that we have considerable maneuvering room here in the form of fraud and waste and profiteering, but early detection and screenings are not all waste and their value may be assessed differently by populations as opposed to individuals. When we say that we shouldn’t spend money on unproven screenings, and if anybody wants one they can pay for it out of their own pocket, we do not reduce costs; we just shift the burden of bearing the cost somewhere else and at the same time increase disparities based on ability to pay. At the rate things change in medicine, who is to say that 10 years from now there won’t be another study correcting the ones we base our decisions on today?
    I agree that a good, and time honored way of reducing health care costs is to push more care to free resources – patients. However, at what point will we be pushing to much? At what point will those without financial and educational resources be penalized? Homeless folks have very little use for home monitoring devices. Caution would be very advisable.
    Another example of every coin having two sides (at the very least), are the Minute Clinics. Getting your A1c at a Minute Clinic is not the most desirable way of managing DM, even if you can pick up your prescription right then and there. Getting your A1c at your Medical Home is a better way. Your doc may pop his head in and say Hi and the NP may notice that your ankles don’t look too comfortable in those new shoes, and maybe we should take a quick peek at that redness and swelling. Convenience and low prices, do not always equal quality. McDonalds is both convenient and cheap, and also arguably responsible for a lot of Diabetes.
    When we say “at the highest possible quality and the least possible cost”, we need to clarify that the highest possible quality we can get for $1 will always be smaller than the highest possible quality we can get for $2. Maybe not by a factor of 2, if we squander the extra dollar, but smaller nevertheless.
    I won’t go into my usual tirade about the iPhone and its, so called, open platform, or all the “free” stuff on the web. I think we all know that there still is no free lunch anywhere and one way or the other you’ll be paying for everything you are getting.
    I do agree though that the Internet is coming to health care and it will bring enormous value and changes in established paradigms for communications, transactions and the availability of expertise. We just need to make sure that those who need it most are not left behind.
    Those that lack quality health care today, are those most at risk of lacking even more quality tomorrow.

  8. Matthew, just wondering if this blog has a policy of taking down comments made by the occasional ignorant pedestrian who wanders in off the web (“tsuris” above comes to mind). Really dummies down this top-shelf blog.
    Joe, you’re spot on! You summarize the Health 2.0 movement when you say, “None of these things will “fix” health care. But collectively they route around its problems and head more directly toward the real value we are looking for — the health of the patient, at the highest possible quality and the least possible cost.”
    This is the promise of H2.0: A trend of faster, better, cheaper work-arounds that leverage the web and mobile technologies to help healthcare evolve and improve.

  9. Yeah, just what I want…. a paraprofessional with a long white coat and pretty smile to misdiagnose my abdominal pain. These clinics should be banned. Give me HIT and give me death! Don’t buy.