Tag: Quality

QUALITY/TECH: Book reviews on quality and technology strategy

Aug 31, 2006• 2

So it’s time for book reviews on THCB. The first book I will talk about is an excellent business written by — full disclosure — my good friend Tony Seba. For several years now Tony has been teaching a course on high-tech marketing strategy. I used to think this was just a chance for him to hang out at Stanford and spend some time in New Zealand, but in fact the course he has developed combines interesting and relevant business cases with general marketing lessons, and most importantly practical explanations of what to do about it if you are creating a business.Now Tony has put his course into a book, so you can get the benefit of his wisdom, without having to go to class. The book is called Winners Take All – The 9 Fundamental Rules of High Tech Strategy. I was really very surprised when I read it because the articles and examples that Tony brings up are things that may appear obvious. But from my time working in even small corporations, I know how hard it is for people to organize and coalesce around getting those things done. Tony’s basic thesis is that for most high-technology markets, one corporation tends to dominate an entire product line. Of course that is not a new theory, but what Tony has successfully done is to identify nine rules that allow companies and products which are in different parts of their life cycle to effectively dominate their markets.

What is particularly useful about the book, beyond the interesting stories and insight you will gain from reading it, is that there are practical ways in which you can put your own project. product or company within the context of the rules. Although Tony is concentrating on high-tech marketing, I think this has many applications for projects and products within the world of healthcare and healthcare technology. And of course any of those of you reading this who are thinking about developing new products for sale to the healthcare industry will have to take the marketing rules deeply to heart.

Interestingly enough, even though I’m pretty sure Tony could have got a standard publishing contract for his work, he decided to publish it at Lulu.com in what he calls a beta version. His argument is that it’s better to get the book out now and to get feedback and incorporate it into the rest of his course and his work, then to take on the traditional 18 months publishing process. But if you go and buy the book at Lulu, which I highly encourage, you won’t be able to tell any difference from a book you’d get in regular store (unless of course you choose to download the PDF version). So not only are you looking at the future of high-tech strategy, you are also looking at the future of publishing. Given that one of the industry’s that has been revolutionized by on demand online access to their product is low recording business, and it’s one that Tony featured in the book, I suspect that the publishing industry should be similarly concerned.

The other book I am reviewing is of a somewhat different flavor. It is one that has been advertising on THCB for the past couple of months, so I felt honor bound to take a quick read. The book is called On Track to Quality, written by James Todd, a professor of pediatrics at Denver Children’s Hospital. Essentially James has developed ten major rules around quality, many of which will be familiar to those of us who have tracked the quality movement in healthcare and outside in the past two decades. I was glad to see the pretty early on in the book he gone in favorable mentions to the greatest book about quality of all time, Robert Pirsig’s Zen and the Art of Motorcycle Maintenance, and in fact the style of Todd’s book reflects some of the qualities of that hippy classic. In the case of On Track to Quality instead of it largely being a discussion between a man, his alter ego and his son on a motorcycle journey, it is a discussion between a group of unlikely passengers on a snowbound train heading across the Rockies. However the passages include enough characters that one suspects that Todd has had some interesting beyond those one would normally associate with an academic pediatrician!

However when one strips away the somewhat stylized way that the material is presented, again in a fairly brief book — it’s just over a hundred pages -there is very useful information about what the quality movement is all about, and a holistic view of how it might be applied to medicine and healthcare. I particularly liked the way each chapter ends with a summary of the rule, and that you could build out the 10 rules and make them relevant to your own situation.

QUALITY/PHYSICIANS/POLICY/POLITICS: Hmm….”questiions” about those chemo payments

Aug 30, 2006• 5

Chemotherapy; Part B “reforms”; bribes to doctors; taxpayer and Medicare patients bilked. Have we heard any of this before?

(I’m sure we’ll hear from Greg soon!)

POLICY/THE INDUSTRY/QUALITY: Why health care costs so much, reason #498

Aug 28, 2006• 10

Two angioplasty procedures on a 93 year old in one week.

Former President Ford underwent his second heart procedure in a week at the Mayo Clinic when stents were placed into two of his coronary arteries to increase blood flow, his spokeswoman said Friday. The angioplasty procedure on the 93-year-old Ford was successful and he was resting comfortably in his room at the hospital in Rochester, spokeswoman Penny Circle said in a statement.

Oh, and this was at Mayo, the bastion of low cost conservative medicine. So if you’re keeping score using the Dartmouth stats that means that if he’d have gone to New York University Hospital, he’d have had EIGHT procedures this week!

HEALTH PLANS/QUALITY: BC California on P4P

Aug 28, 2006

My erstwhile colleagues at FierceHealthcare have an interview up with Dr. Michael Belman, staff VP and Medical Director, Blue Cross of California. It’s a pretty good introduction, for those of you who don’t know much about it, to the P4P program in California.

On the other hand they never asked him what kind of wonderful results that Wellpoint got from dumping $40m worth of computers onto the doctors of America without any metrics or intent to actually make them integrate said computers into their workflow. (I suspect eBay got some sellers’ commissions out of it, though). Nor did they ask whether paying for performance includes paying bonuses to their underwriting staff to find ways to cancel members’ policies retroactively.

Oh well, perhaps that’ll be in the next interview!

QUALITY/POLICY/HEALTH PLANS: Cranky, confused, aimless and spineless

Aug 21, 2006• 1

And in the all talk and no action department…

Ian Morrison and Bob Leitman used to go around America calling employers’ attitude towards buying health care for their employees“cranky, confused, aimless and spineless”….that was in the early 1990s. It’s all different now, eh? Well not quite. Deloitte survyed 71 big employers to find out how they were cracking the P4P whip on the system.

The joint Center/ERIC study looked at the views and attitudes of 71 major employers on value-based purchasing, also known as “pay for performance.” Some 10 percent of respondents are currently engaged in value-based reimbursement programs with health plans and/or provider networks, indicating a growing receptiveness to developing regional or pilot programs. However, 38 percent of surveyed employers are waiting for more concrete evidence that the concept can deliver a better return on investment.

Hmm.. so only 10% of big employers are doing anything about P4P. Employees working for employers with more than 1,000 employees represent about 13% of the private sector workforce (yup I scouted the Stat Abstract for that number). So less than 2% of employers are doing anything about P4P. In other words not enough for providers to take note of, so nothing will happen until Medicare makes its move.

QUALITY: More from the DM conference

Aug 2, 2006• 2

QUALITY/TECH: Disease Management conference in Boston

Aug 1, 2006• 6

Musings from the conference on disease management…..it’s hot in Boston but a few musing from presentations

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Cheap interventions in DM work. Cutting co-pay costs to close to zero and adding pharmacists doing education for chronically ill people in a commercial population makes a big difference. Barry Bunning runs the Asheville project (in North Carolina) which has a ten year history of this and have seen costs for this group go down by about half over that time—with success even in the first years, even though it cost several hundred dollars per patient—and saw continued trend reductions versus comparable national stats. Pretty damn interesting and perhaps we don’t need much more higher tech information.

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Medecision (Henry DePhillips, med director)—started with putting the payers in the business of predictive modeling and matching and is putting that information in the hands of the docs during the physician patient relationship….but claims that only 13–5% of provider data is ready to be assessed, whereas of course none of the personal health record stuff is, and of course all the data has got the payer, and that’s all extractable and electronic. So they can present it in what they call the PBHR (payer-based health record). Their patient clinical summary extracts data from payer systems, summarizes it, and moves it to the doc at point of care. The summary has:

demographic information,
main diagnoses,
a health status measure (derived from the data)
a medical problem list,
then inpatient or ED admissions (with discharge information) in recent years,
useful CPT data from physician visits (including not yet the lab test, but the fact there was a test and who ordered it with their phone number),
the medication list,
doctors already seen
and finally the nursing plan of care content.

Designed for ER docs—most useful is medication list, then docs they’ve seen and phone number, and previous test knowledge. Will be modifying this out. Have already interfaced this into 5 personal health records, to pre-populate. But the main way it’s used is printed out by the triage clerk in the ER or by the front desk clerk in a physician office,.

Just got the results of a financial study (from HealthCore) looking at the use of this in a trauma center over about 9 months (with cases and controls) 918 visits and transmissions. If you take into account the ER episode plus the first day of hospital admission saved $545 per transmission of the record. This showed also NO difference in hospital admit rates. What were the differences? Lab costs much lower; cardiac cath costs much lower as previous; medical and surgical supplies costs lower; physician cognitive care component INCREASED in this population, which probably means that they made the unknown known (i.e. the patient was actually sicker so needed more) . So the payer saved, the doc made slightly more, and the hospital saved on ER throughput time (theoretically can see 9,000 cases more per year, although they make less on each case!)

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I met someone emblematic of the problems of employer based health care. She’s an RN who moved jobs and in the process was financially devastated by first her kids four days in pediatric intensive care after an asthma attack (somehow this was pre-excluded from her employers insurance) and then immediately afterwards her husband needing a by-pass. She was five years from paying off her mortgage with no debt, and now will never be able to retire. Only after the third hospitalization did she realize that the hospital would give them a discount, and of course they charged her the rack rate. She said the worse thing was not knowing about all the potential social support—including from the hospital. This is a straight case of someone working hard, playing by the rules and being totally screwed by the health system.

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Also heard an amazing talk from Dave Moskowitz from GenoMed. Dave has been on THCB before, and he believes that he can reverse disease….and that consequently the entire medical establishment has been shutting him out. Amazing stuff; I of course have no idea if it’s true, but I have a sneaking suspicion that he understands the incentives pretty well!

QUALIY/PHYSICIANS: P4P in the United Kingdom

Jul 27, 2006• 2

The biggest P4P scheme in the world is going on in the UK, one that I first wrote about in early 2004. (For more on the wider ramifications of reform in the UK ,see yet another article in this weeks NEJM)

Note that all the GPs there have computers, so they can easily report their process behaviors. Note also that the introduction of the system as done as a way of giving extra cash to GPs, but extra cash for improving quality of primary care process. So the first year’s results are in, and the GPs have done much better than was predicted and better than most American groups studied other than the VA. I think this is so important in the light of where Medcare is going that I’m including the entire discussion section from the NEJM article from the Univ of Manchester group that studied it. It’s called “Pay-for-Performance Programs in Family Practices in the United Kingdom”, and its below the jump, as an exceprt from an article by Arnold Epstein commenting on its implications for the US

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TECH/QUALITY/PHYSICIANS: Healthcare and The Long Tail – Searching for help when you’re on the wrong-end of the curve by Jim Walker

Jul 26, 2006• 5

Two things have got my attention recently. The first is the concept of the long tail in medicine, which I’ve thought about alot since my fiancee got an odd condition (shortness of breath) that didn’t match any of the symptoms the text books said were the symptoms of the usual shortness of breath. She endured several doctors diagnoses of diseases that went from the wrong to the ridiculous (panic attacks that lasted for weeks?). After much, much digging around on the web she found a patient testimonial from someone who had long term shortness of breath and related it to caffeine. Yup, drinking coffee was causing the problem. But because it was a rare symptom of what’s not normally a medical problem she had to go through the annoyance (and worry) of being wrongly diagnosed and put on drugs she didn’t need, and now she can’t drink coffee or eat chocolate—her life must barely be worth living!

The second is a plethora of people writing to me telling me about XYZ product that is the greatest since sliced bread and would I please praise it on THCB. One such person is Jim Walker from new physician social networking site MyMedwork. Usually when I request that said person writes a piece putting their service in context I get self-serving marketing jargon, and when I request that they instead really write a general interest piece I never hear from them again. In contrast Jim wrote an excellent explanation of the Long Tail in health care. Here it is:

Healthcare and The Long Tail

By JIM WALKER

My neighbor brought her son to the doctor this summer for a rash that
wouldn’t go away. “The doctor had never seen anything like it,” she
explained. “In fact, he brought in the other doctors to take a look at
it, and none of them had ever seen it either.” Now I don’t know about
you, but listening to her reminded me of my worst medical nightmare of
things I don’t ever want to hear from my doctor: “Excuse me, do you
mind if I bring in some of the residents? We’ve never seen a case like
yours before.”

In a recent THCB post,
author Maggie Mahar writes that “Ambiguity haunts medical care”. She
goes on to quote Dr. Atul Gawand – “Uncertainty is the core predicament
of medicine . . . the thing that makes being a patient so wrenching,
being a doctor so difficult and being part of a society that pays the
bills so wrenching."

It’s important to note that for a great
many cases, ambiguity is not really an issue. This is because the
distribution of medical ailments follows a curve very similar to Chris
Anderson’s “Long Tail”,
with a great many common “blockbuster” ailments stacked up high on the
left-hand side of the curve. For those not familiar with the Long Tail,
Anderson describes how Amazon, Netflix, and other online retailers sell
lots of the usual blockbusters, but actually derive more total volume
from 100s of thousands of niche products. In healthcare, it is the
left side of this distribution curve which inspires (for better or
worse) Wal-Mart, Target, and others to offer “Doc In A Box” services –
Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye,
Sinus Infections, and a full battery of vaccines – all served up for a
fixed price while you wait.

On the right hand end of the
curve though, the NIH Office of Rare Disease classifies over 6,000
conditions, each afflicting fewer than 200,000 Americans. Along this
part of the curve, things do indeed get very ambiguous in a hurry –
both for patients and physicians. Specialization is a response to this
range of ailments (“nichefication” in Anderson’s terms), and brings
physicians repeated cases of a particular nature – giving them the
confidence that they can routinely diagnose and treat a high percentage
of these patients. However, even within a particular specialty area,
cases will naturally follow a distribution curve from typical to
atypical. Unto themselves – atypical cases are just that – one of a
kind aberrations that force physicians to go outside their typical
“comfort zone” of diagnosis and treatment. For each individual
physician, these atypical cases feel like the exception rather than the
rule. What the Long Tail suggests though, is that taken in their
entirety, these rare cases actually compromise a large percentage of
all medical cases. In fact, over 25 million Americans suffer from a
“rare” condition.

This is problematic, because in general,
physicians – and the healthcare system as a whole – are not well
prepared for dealing with the many and inevitable rare cases. In fact, statistics show
that the median time to diagnosis of a rare condition is six months,
and the average is almost three years! When faced with an atypical
case, most physicians will begin to consult the literature, and/or
confer with their colleagues. Ironically, it is at this moment that the
Long Tail shows up again in a quite surprising and often detrimental
fashion. This is because recent studies in social and information
analysis reveal that our network of professional contacts and
information sources follows the same type of distribution curve. In
other words – we all generally tend to connect with the same 15 or 20
trusted colleagues on a regular basis, and we all gather our
information from a limited stream of trusted sources. Beyond this
trusted core lies an entire world of other people and sources we rarely
connect with, if at all – our own social and information “long tail”.
Generally, using a network of trusted sources (while tuning out most
everything else) is actually very efficient at handling a majority of
our day to day needs. For the atypical situation though, just when we
really need to break out of our habitual way of doing things – our
trusted sources generally don’t deliver. They’ve all been drinking from
the same information punch bowl.

So, we have to head out to
the right-hand side of the curve – and begin finding and evaluating
people and sources we don’t really know. For a student or researcher,
this type of research can become a time consuming, challenging, but
often rewarding journey. But, for a patient and physician confronted
with a puzzling and life threatening illness, the stakes are much
higher and time is at a premium. In today’s system, the physician often
must address this dilemma by referring the patient to some other
specialist – with the hope that maybe they will have the knowledge or
connections to form a proper diagnosis and treatment protocol in a
timely manner. The patient of course, must continue to move from
specialist to specialist, their rare case still in hand.

Not
surprisingly, the Internet has proved both boon and bane in this
situation. Patients and their families are using the Web to dig into
the latest medical research. However, matching a worried patient or
family member against 1,706,532 Google results is usually a
prescription for both confusion and high blood pressure.

On
a more encouraging note, patients stuck along the right-side of the
curve with a “niche disease” are using the extraordinary reach of the
Web to discover that they are not so atypical after all. It’s probably
no surprise to THCB readers that patients are banding together around
wikis, chat rooms, blogs and social networks to offer each other
information, empathy, and inspiration. (This is not so different in
network theory terms from when fans of a niche band find each other on
MySpace). Some of these disease state patient networks are sponsored by pharma marketing, while others are grass-roots efforts, usually led by a parent or family member related to one of the patients.

Physicians
are also turning online in large numbers. Manhattan Research reports
that more than 600,000 physicians are using search engines to find
medical information. Are they searching about how to treat their
day-to-day typical cases? Very unlikely. Chances are, they are
researching an atypical case. However, if two physicians search – for
example, on “phylloides tumors” at Google they each receive the same
list – but have no easy context by which to evaluate the 13,600 +
search results!

Social network software may be one way to
help physicians overcome this “search result overload”, allowing them
to move faster and more confidently outside their circle of trusted
sources and down the long tail, especially when faced with a “rare”
condition (which as we’ve noted – is not such a rare occurrence in the
aggregate). For example, within MyMedwork
, search priorities start with the individual physician’s network of
trusted colleagues and work outward from there. In other words – each
physician gets a totally unique list of search results based on who in
their own extended network is likely to possess useful information.
Because the medical community is so small, it turns out that physicians
are usually quite closely linked to any given article or study, they
are just not aware of the connection. By viewing the social network
connection within their search results – they are then in a position to
more accurately judge the quality of the information – either by
checking with the in-between link (i.e. “Hi Dr. Jones, I notice you’re
connected to Dr. Watson – what do you think of his study on phylloides
tumors?”) – or by contacting the physician directly (i.e. “Hi Dr.
Watson, I see you went to medical school with my colleague Dr. Jones,
do you mind if I ask you a few questions about your study?).

The
implications of The Long Tail and social network analysis for
healthcare are just beginning to be explored and understood. It is
already clear though, that as the entire healthcare field continues to
undergo dramatic change, and “atypical” rare disease states become ever
more typical, ambiguity and uncertainty will continue to impact medical
decision making. In this environment, the need to develop richer and
more varied sources of information, and the value of far-reaching,
online social trust networks will become increasingly apparent for
patients and healthcare practitioners alike.

YOU’VE GOT MAIL

Or we’ve got mail. Or we’ve all got mail. Or something …

After much late night heroism by THCB’s trusty (and highly
sensitive) tech staff, the THCB email list is up and running. If you’d
like to get a quick email in your inbox with a rundown of new posts –
with news flashes for important stories – you can sign up here.

If you subscribed to the list in its earlier incarnation, there’s no need to do so again.

QUALITY/CONSUMERS: A really personal piece about obesity

Jul 21, 2006• 1

From Pat Salber at The Doctor Weighs In, here’s a very personal look at the life of someone extremely obese as a side effect of diabetes . Well worth reading, even if it might spoil your appetite and get you to check up on your blood sugar levels.