Healthcare’s Age of Enlightenment
The Age of Enlightenment brought us crucial discoveries and inventions in many areas including optics, the circulation of blood, scientific classification, gravity, the microscope, calculus and more while serving as inspiration for the Declaration of Independence and the U.S. Constitution. For good reason, it was called a revolution of thought. It is self-evident that we are in the early days of healthcare’s Age of Enlightenment that will be just as dramatic in terms of its long-term impact. Bold new ideas in healthcare delivery freed from tradition and dogma are resulting in dramatically better outcomes. These ideas both catalyze and are enabled by new technology.
Over time, themes emerged in the Age of Enlightenment, as they will in healthcare. Based on what I have observed so far, I have seen seven major precepts gleaned from healthcare’s Enlightenment thinkers that I have outlined below.
1. True Patient-Centricity is Healthcare’s Copernican Moment
Copernicus was the initiator of the Scientific Revolution. In turn, a result of the Scientific Revolution was the Enlightenment. The healthcare providers who have over-achieved on the Triple Aim have achieved their Copernican Moment. That is, the recognition that when the individual (aka the patient…not the provider) is at the center of the healthcare universe, the system realizes its full potential. It’s also when providers move beyond viewing patient engagement as a nice-to-have effort led by marketing to central to success in achieving the Triple Aim — which is core to success in the fee-for-value era. After all, we spend more than three-quarters of healthcare’s spend on chronic disease where the majority of the decisions that most impact outcomes are not made by professionals. Rather, it’s the patient, family and caregivers who make the crucial decisions such as diet, exercise, lifestyle, filling prescriptions, properly adhering to prescriptions and so on. Further, when patients and caregivers are part of the decision process, they are more successful at achieving prescribed courses of action. There is growing recognition on the part of the professional members of the care team that it isn’t so easy to be a patient.
Enlightened healthcare organizations have long since learned that to ignore patients is at one’s own peril. With good reason, the phrase Patient Engagement is the Blockbuster Drug of the Century has become one of the most common for healthcare’s Enlightenment thinkers.
Just as entire new fields of study emerged from the Age of Enlightenment, the same will be true for healthcare’s Age of Enlightenment. One of the first and biggest revolves around providers developing patient engagement skills. It’s overstating to say that not since WW II has there been a more dramatic need to retool several professions. The fact is most healthcare professionals weren’t trained in the patient engagement skills required for success going forward. Fortunately, there are some great initiatives underway. I’ve had the pleasure to spend time with the medical education community over the last year (disclosure: my employer’s (WebMD) Medscape Education division is a provider of independent medical education). I couldn’t be more excited about what is in the works in the medical education community.
Even enlightened providers still operating in the fee-for-service world understand there is a strong business case for engaging patients. Patient engagement skills transition from a source of competitive advantage to a matter of survival in the rising fee-for-value era. [Read more in The 7 Habits of Highly Patient Centric Providers.]
2. Empowering the Healthcare Partnership: Care Networks Optimize Health Relationships
Like a world class crew team, healthcare realizes its full potential when there is a partnership between the individual and all members of their care team. Daniela Drake, MD, MBA put it this way:
An ‘enlightened’ system will recognize that at its root, communication is a two way street and partnership has two people in it. Yet, consistently, physicians are left out. Why? Who would enter into a marriage where the minister says, “I now pronounce you the person who gets all your needs met and you the person who will service those needs”?
Dave deBronkart (ePatient Dave) has spoken in many venues how his physician (Dr. Danny Sands) was instrumental in his care. At the same time, he highlights how patient-centricity can be misconstrued.
Too many people think about the Copernican shift, but still think about that now-at-center patient as a passive thing that gets healthcare done on it. But when patients point out those errors in their charts, they’re actively creating value in the ecosystem.
Today’s healthcare system puts doctors in the unfortunate position of being the blind man describing the elephant. That is, they know a particular part of the patient’s body very well but rarely have the complete picture of their patients’ health. Enlightened providers are the top performers in population health because they are able to get a more complete view of the patient. The promise of Health Information Exchanges (HIE) has been that it will make the whole patient view easier. However, twenty years of evidence suggests HIE has too many structural impediments to broadly succeed. Instead, the de facto “HIE” is a blend of 15 billion faxes going between providers combined with whatever sheets of paper a patient carries around or can remember in their head.
Instead of HIE, healthcare’s Enlightenment thinkers recognize that a patient-controlled, networked Collaborative Health Record (CHR) that blends together an individuals family medical history, health habits, and biometric data with institutionally provided information from multiple EHRs, labs, pharmacies, radiology and genomic data provides a far more complete picture. In healthcare, a HIPAA-compliant asymmetric model is what is required, as not all information should be broadly shared (unlike symmetric social networks where all info is shared equally). For example, a doctor and patient benefit from a connection, however a doctor may also want to connect with other doctors for a virtual curbside consult. Further, a patient may want to share all of their medical information with their primary care physician including information from their dentist, physical therapist and psychologist. However, it doesn’t mean they want to share all of their medical information with their dentist (nor does the dentist want all of their patients’ information).
Most people didn’t notice a wise ruling by the Office of the National Coordinator (i.e. the HHS department overseeing healthIT) that is a catalyst for multi-provider patient relationship management that is far superior to silo’ed patient portals. One doesn’t have to be particularly sick to be in a position where they have 5–10 different patient portal silos. For example, my family has been healthy and we still see seven providers in a typical year (not to mention we have moved between three states and four counties in the last 4 years). I have yet to meet the person who says they want seven different silos of health information requiring seven different user IDs and passwords. It’s worth noting that this patient-as-systems-integrator issue grows with the proliferation of mobile apps, biometric devices and more tools that add yet more user IDs and passwords along with silo’ed data.
A clear indication an organization hasn’t had their Copernican moment is when they believe a silo’ed EHR-based patient portal that isn’t patient controlled is an example of being “patient-centric” when it is the definition of provider-centric.
3. Health Literacy Enabled by Providers
It’s well understood that educated patients have better health outcomes. Today’s enlightenment providers have found it much easier than before to educate their patients. I liked how Christina Hoffman, MS who is the Executive Managing Director, for Medscape Education described the challenge facing doctors and patients today. She pulled out a pen and pushed it straight down on the table using that as a metaphor for the great pressure that is applied to the clinic visit — a brief moment in time. The patient feels pressure as they have issues they are sometimes unable to describe clearly (or even remember to ask). Conversely, the doctor has a tremendous amount of time pressure to understand what’s going on both medically and psycho-socially in order to assess what’s going on and then prescribe a course of action and patient education that will improve the patient’s life (not to mention administrative/billing functions she must complete). Continuing the metaphor, if the pen is turned on its side and rather than all the pressure on that one point in time, there is a longer period of time before and after the clinic visit, a lot more can be accomplished spreading the pressure out.
Recognizing the underpinnings of that phenomenon, many doctors took a different approach that I first described a few years ago about flipping the clinic visit. For the same reasons the Khan Academy flipped the classroom, these Enlightenment doctors recognized there was a better way. More recently, the Robert Wood Johnson Foundation has created a new program called Flip the Clinic meant to accelerate the adoption of this approach.
As anyone can see in the infographic below, consumers are spending far more time on the Internet consuming health information than they do with their doctor (typically people spend ❤0 minutes per year with their doctor). Enlightenment doctors realize that their patients can get much more out of that experience if the doctor helps curate the information their patients are consuming. Everyone knows there is a tremendous amount of good and bad information on the Internet. Doctors can play an invaluable role curating the most useful information just as a museum curator reviews thousands of pieces to select a few that get displayed. In the process, the doctor gains efficiency (rather than repeating the same information over and over) while providing a more tailored encounter.
4. Healthcare’s Most Important Medical Instrument is Communication
“A good scalpel makes a better surgeon. Good communication makes a better doctor.” — Josh Umbehr, MD
It’s stating the obvious that effective communication is important during a clinic visit. However due to legacy reimbursement distortions, the other 99+% of the patient’s life away from the clinic tends has been short-changed. Enlightenment physicians are expanding their communication skills to the wide array of communication tools that we take for granted in the rest of our lives but tend to be the exception in healthcare. If a provider is to succeed in the fee-for-value era, they must place as much or more focus on the time the patient is away from the healthcare facility as when they are in an office visit.
“I don’t think you can overstate the importance of communication in clinical care. Even with devices, robotics, genomics and personalized care, it all rests, and depends on, clear communication.” — Wendy Sue Swanson, MD, MBE, FAAP
Pre-Enlightenment health IT had patient communications as an afterthought. Enlightenment healthtech builds in patient-provider and provider-provider communications as a central design point of their architecture. There is a reason SAP or Oracle didn’t become the de facto consumer communications tools for companies as they empowered consumers to interact. Instead organizations are relying on a range of tools such as Twitter, Facebook, ExactTarget, Zendesk and more to communicate with consumers. Simple patient portals are like a muddy puddle of water in the Sahara Desert — an improvement over no communications but far from ideal. Enlightenment providers recognize they must find the healthcare equivalents of ExactTarget, Facebook, Twitter and Zendesk rather than expecting those tools to come from legacy healthIT vendors who are the equivalent of SAP and Oracle. That is, they are critical for internal processes, but not optimized for consumer engagement.
5. Patient Data and Insights are the Greatest Source of Truth
The fathers of the Enlightenment, Francis Bacon & Renee Descartes, proposed a rational approach to science that would free them from ignorance. Until recently, it has been infeasible to get a dramatically more complete view of what’s going on with a patient’s health. As Enlightenment providers such as CareMore have demonstrated, remotely monitoring CHF patients’ weight on a daily basis can dramatically improve outcomes and the patient’s quality of life. The Enlightenment brought us the Scientific Method where generalized conclusions were based on careful observation. Likewise, remote monitoring allows for careful observation that is far superior to monthly or quarterly visits, which represent a tiny fraction of a patient’s life. Enlightenment providers relish a more complete picture of their patients. Too often, they only have a few puzzle pieces that make up the complete view of a patient.
Vinod Khosla has been a provocative thinker and describes how technology can make up for human deficiencies while amplifying our strengths:
Healthcare will become more scientific and more consistent, delivering better-quality care with inexpensive data-gathering techniques, continual monitoring, more rigorous science and more available and ubiquitous information leading to personalized patient insight. Many new findings will be outside the reach of most physicians because of the volume of data and the unique holistic insights that data will provide about a patient’s very complex condition. Hundreds of thousands or even millions of data points may go into diagnosing a condition and monitoring the progress of a therapy or prescription, well beyond the capability of any human to adequately consider.
When the Robert Wood Johnson Foundation (RWJF) funded the Open Notes project, there were many expectations of a negative impact on physicians. Instead, physicians were pleasantly surprised with the results and patients were overwhelmingly positive. Naturally, no one knows more than a patient about what’s going on in his or her health. Dave Debronkart (aka “ePatient Dave”) surveys the thousands of people he speaks to every year. Dave has said, without exception, that every audience he polls find that two-thirds of those people who have access to their records find an error. Some errors are more serious than others, but there isn’t a clinician in the world that doesn’t want the most accurate view of a patient so they can do their best work.
The OpenNotes movement is taking the next step with their OurNotes project. It will test the concept of having patients add to and update their own electronic medical records.
6. Solving Healthcare Requires Primary Care Renaissance
The countries with the best access to highly functioning primary care have the healthiest populations and spend lower per capita on healthcare. Every government and business is budget constrained and these findings will be hard to ignore. IBM’s Dr. Paul Grundy has been a leader along with executives at other large corporations encouraging more focus on primary care in health reform and elsewhere. There are several other reasons primary care is due for a renaissance.
Awhile back I wrote about The Marcus Welby/Steve Jobs Solution to the Medicaid-driven State & County Budget Crisis. We are now seeing next generation primary care thriving in the state of Washington, which is arguably the strongest state for primary care. For example, Washington is home to the top rated primary care program at the University of Washington Medical School. Further, innovative new primary care models such as Direct Primary Care (DPC) have been invented in Washington. The state of Washington was also the first state to explicitly enable DPC where it’s used in Medicaid and the public insurance exchanges resulting in explosive growth for the pioneer of DPC, Qliance.
7. Enlightenment Requires Constant Learning and Agility
Health systems have been understandably hospital and procedure centric as a result of the historic, FFS reimbursement model. Having been a part of many large-scale systems implementations, I’d characterize them as automating highly complex manufacturing processes. Consequently, there is an immense amount of time understanding and determining processes that get codified in highly customizable systems (if you ever wondered why healthIT implementations can cost 100's of millions and take years, this is why). However, once customized, they are quite rigid. That is fine when, say, surgical processes and checklists get standardized.
Naturally, to stay enlightened, one must constantly learn from experience and observation. The reality is that the pace of learning and change must be dramatically higher when you have the near-infinite combinations of chronic conditions and one’s inherited and developed health attributes. For example, understanding a HONDA (hypertensive, obese, non-compliant, diabetic, adult) versus a young adult with diabetes demand a different approach. This is why an organization’s agility will determine whether they are the market leader of the future. As outlined in the previously linked to article, it’s critical that the technology architecture is closer to how a direct marketer operates (i.e., constantly testing, iterating, improving) than how a manufacturer operates.
The need for agility and speed is a key reason most of the providers best positioned for the future developed their own home-grown healthIT solutions. As their practices move mainstream, that is when a commercial software market solution becomes viable. The IOM wrote about this in Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Key Players are Responding
Enlightenment Thinkers: These revolutionaries (of thought) are scattered around many organizations. They gather at events such as Health 2.0, Oliver Wyman events, MedX, TEDMED and virtually (e.g., Twitter, comment threads on The Health Care Blog). Balaji Srinivasan (Andreessen Horowitz partner) argues in Wired that the virtual gatherings may prove transformational. Until that happens, the equivalent of the salons of the Enlightenment are taking place in healthcare. Healthcare’s Enlightenment thinkers are highly frustrated with the status quo and highly motivated to drive dramatic change.
Employers: More and more CEOs and CFOs recognize they are failing in their fiduciary duty to their shareholders if they don’t effectively manage healthcare costs since it’s typically the second or third largest cost item for an organization — enlightened employers understand healthcare benefits be a source of competitive advantage. The two most common methods of optimizing healthcare are overhauling their approach to primary care and high cost procedures. The old adage “an ounce of prevention is worth a pound of cure” applies. On the latter, there are a few models emerging — some driven by surgical centers while others are initiated by employers. CEOs/CFOs should be codifying the Choosing Wisely recommendations in their health plans while ensuring their benefit recipients understand these recommendations are benefitting them (many mistakenly believe more healthcare is always better).
Pharmaceutical and Medical Device Companies: Enlightened pharma and device companies seek to follow IBM’s path of reinvention rather than make the classic railroad industry mistakes. As their payment gets more directly tied to outcomes, the enlightened pharma and device companies are wisely making increased investment in patient education and engagement.
Providers: Below I mention individual physicians who are leading Enlightenment thinkers. The organizations employing these individuals would be wise to tap their wisdom. The list of initiatives enlightened providers are doing could be the subject of a book. For a sampling, read about those organization doing some of the best work here.
Health Plans: Early health plans that invested in patient engagement were commonly integrated delivery networks. For those health plans that aren’t integrated delivery networks, enlightened plans recognize how supporting patient engagement programs at providers is a great way to reposition their organizations. See Patient Engagement, Negaclaims Can Reposition Health Plans.
Most of the precepts are evident today though there is some speculation embedded as well. Enlightenment thinkers are quick to note that any one particular prediction is unlikely to be reality, however some improbable scenario will become tomorrow’s reality. The point of the predictions isn’t that they are absolutes. Rather, they are “more true than not” speculations as Vinod Khosla states. The objective is to imagine the “impossible” and then strive to make it a reality. Considering that one study of a Cleveland Clinic second opinion program found that a new plan or significant change in prior treatment happened in 90% of the cases, it’s not a new concept to medicine that we don’t have perfect vision about the future.
Healthcare’s Age of Enlightenment will inexorably drive the future of healthcare as models get iterated and the cycle of learning accelerates. As Susannah Fox stated, “The most exciting innovation of our era is not access to medical information, but access to each other” — a point made in Balaji Srinivasan’s Wired piece. In fact, it’s the access to many Enlightenment thinkers that I attempted to summarize here.
The list below are individuals who directly impacted what I wrote (many more indirectly influenced it) with links to their work/thoughts:
Dr. Don Berwick, Dr. Garrison Bliss, Dr. Natasha Burgert, Dr. Steve Davidson, Dave deBronkart, Dr. Wen Dombrowski, Dr. Douglas Eby, Tom Emerick, Dr. Rushika Fernandopulle, Susannah Fox, Dr. Adrian Gropper, Dr. Paul Grundy, Regina Holliday, Dr. Lee Hood, Dr. Leslie Kernisan, Vinod Khosla, Leonard Kish, Dr. Daniel Kraft, Vince Kuraitis, Dr. Rob Lamberts, Dr. Howard Luks, Tom Main, Dr. Bob Margolis, Dr. Farzad Mostashari, Katie McCurdy, John Moore, Jan Oldenburg, Dr. Mike Painter, Todd Park, Lygeia Ricciardi, Sherry Reynolds, Bryan Sivak, Balaji Srinivasan, Dr. Wendy Sue Swanson, Dr. Craig Tanio, Dr. Grace Terrell, Dr. Eric Topol, Brad Tritle, Dr. Bryan Vartabedian, Dr. Greg Weidner, Dr. Sue Woods, Dr. Sheldon Zinberg.
[Postscript: This is a living document that would benefit your input. Most likely, this will be broken apart to make it more digestible for a general audience (if you got this far, you are ahead of the curve). Let me know if you think it misses or hits the mark. I welcome your feedback here or privately. Thanks!
I should also state that my intent is to counter the gloom some have about the dramatic in healthcare. Sometimes lost in the fray is is the amazing work and highly satisfied physicians/leaders driving new models. At the same time, as one of those change agents (Dr. Rushika Fernandopulle) put it, “there are lots of barriers — stupid regulations, providers putting up barriers to new entrants, payers without any guts, etc.” Despite this, organizations such as Dr. Fernandopulle’s are enjoying success while having Net Promoter Scores that put Google or Apple to shame.
Interestingly, I’ve gotten diametrically opposed feedback (in private emails) that I left out either the physician or patient. I take that to mean that I should talk more about the partnership between the two so I’m took a stab at that (see item #2).]
Originally published on www.linkedin.com.