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Patients As Designers Of Their Own Health

Seattle’s grassroots healthcare community continues to gain traction with a new meetup for patient-centered design. Last week’s meeting was generously sponsored by MCG a subsidiary of Hearst Publications who are quite active in the healthcare world with content and education. The panel discussion featured Dana Lewis, a patient-maker who is active in the open source movement for diabetes care and built her own artificial pancreas, Christina Berry-White from the digital health group at Seattle Children’s, and Amy London, Innovation Specialist at Virginia Mason. The group talked about how to effectively get feedback from patients, and how patient hackers like Dana can take poor design into their own hands build tools they need, and ultimately influence large healthcare companies, in this case device manufacturers.

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Dana, Christina, and Amy, photo credit Alina Serebryany

The panel had great advice for understanding and developing products and improving processes for patients, as well as for soliciting feedback from patients. Here are a few of my takeaways.

Tips for developing products and process

  • Understand patient’s goals and desires. Often the goals of the hospital or health system are not the same as the patient’s. After meeting with a group of patient advocates one Virginia Mason surgeon realized that the only outcome that really mattered was whether the patient had a positive experience.
  • Let patients customize their views and experiences. Amy talked about a particular chart where she wanted to see the graph rising to show increasing blood sugar and another user she talked to wanted to see the graph lowering to show insulin lowering and a need for intervention. Amy was confused by this view but created her open source artificial pancreas interface to enables people to choose their own view, and the result was that people who had diabetes looked at it the same way Amy did and parent-caregivers of diabetic children wanted the second view. Which brings us to the next point–
  • Differentiate between users. Patients often have different requirements than their caregivers, whether that’s parents caring for a child or teen, or adult children caring for a parent. As well, the clinical workflow shouldn’t dictate the patient experience.
  • Get feedback early. Amy mentioned meeting with a device manufacturer who showed her an almost ready for release glucometer that was intended to fit in the pocket. She quipped “you obviously didn’t test this with women’s pockets.”

Tips for collecting feedback

  • Build it into the product. Christina from Children’s mentioned that when they switched from reams of paper to an iPad-based tool for patient on-boarding forms the physicians wanted to stop using it because it did not immediately integrate with the EMR. Luckily the tool had a feature to survey users on whether they preferred using it to paper, and the answer from parents was overwhelmingly yes. The digital health team showed these results to the physicians, and the tool stayed in place.
  • Be creative when soliciting feedback. Children’s knew from experience that parents and patients were reluctant to give them negative feedback after a lifesaving experience like an organ transplant, so they used techniques that are often used in brand market research: analogies. For example, they asked teens to describe a digital tool as a car, and found out that their tool was like a pick-up truck to them: useful but utilitarian.
  • Use patients to collect feedback. Patients are also often intimidated to provide direct feedback to healthcare professionals as they see them as authority figures. At Virginia Mason patients who have already had a successful joint replacement visit post-surgical patients to find out how they are doing, and talk about their own experiences. Patients are a lot more candid with each other, and Virginia Mason was able to benefit from understanding the questions they asked the peer ambassadors and incorporate that information into formal programs.
  • Ask the questions at the right time. If you want to understand post-operative experiences ask within a few weeks of the actual experience, not 6 months later.
  • Be aware of selection bias. Patients who volunteer for focus groups are often those who have the time and money to be able to do so. Your feedback may be skewed towards retired patients, and those who are not hourly workers. Consider how you will cast a wide net.

Lots of great advice at this event, much of which we already incorporate into our processes and products at Wellpepper, although I definitely got some new ideas and it’s great to see the community coming together to share best practices. My only disappointment with the event was that with a title of Patients as Designers, I expected to see more patients on the panel. While there was a last minute cancellation of a patient-maker, it would have been amazing to have Children’s and Virginia Mason bring one of their patient-designers to be on the panel. Maybe next time?

Posted in: Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Lean Healthcare, Research, Seattle

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Cross-Fit for Healthcare: An HX360 Workshop

At the recent HIMSS 2016 conference in Las Vegas, Robin Schroeder-Janonis, Wellpepper’s VP of Business Development,  and I were up early for cross-fit. Not the total body workout you may expect, but a workout nonetheless in the session “Innovation Cross-Fit” facilitated by Leslie Wainwright, Molly Coye, Gregory Makoul, and John Kutz. The cross-fit in this session referred to cross-organizational teams, the type required to implement innovation in healthcare and the workout took the form of a workshop where participants determined how big of a lift it would be to implement a new innovation.

Each table was comprised of a cross-section of senior healthcare leaders including CIOs, CEOs, business development, innovation leaders, IT, and marketing/communications. As a warm up, we were asked to evaluate the effort to implement a new innovation from a number of axes including user experience, implementation, stakeholders, path to scale, and opportunity. Our table was asked to evaluate the Proteus Discover Platform, a new category of ingestible medicine. We were given a high-level brief of Proteus and set loose.

In evaluating the “lift” for Proteus our group took into consideration a number of factors. First, while the population that would receive the ingestible medication would be relatively small, the legal and privacy impacts could be huge. As a result, we ranked higher complexity on user training and stakeholders, particularly with respect to medical users who would need to explain how the medication worked. Implementation costs were low as there was no IT involvement and no new hires, and only some new hardware required.

Here’s an example of the scorecard from our table:

Cross-Fit For Innovation

The next step was to map the implementation journey by adding steps in the process and stakeholders involved at each step. Our group started with the process steps and added stakeholders after the initial process was mapped out. Others fully explored each step before moving on to the next in the process. We found that there were a few stakeholders missing from the provided stack, for example although this was a medication we didn’t have a sticker for pharmacists, and that we had stakeholders participating in multiple process steps: patients and end users for example were seen at multiple stages.

In this stage the interdisciplinary teams brought their own experiences and filters to the table, which resulting in a more inclusionary process. For example, marketing representatives suggested that although the board of directors was not required to approve the implementation because the budget was so low, that they should be on an FYI list before any press releases related to using the new technologies. Operations people pointed out that procurement was left out of the process initially, and yet they’d have to sign the contracts and issue the POs.

Here’s what the process looked like from my group:

Innovation Journey Map

Finally, groups presented to each other, and this is where things got really interesting, as you can see the approach differed significantly across groups. Our group heavilty weighted the beginning of the process while another used iteration to get the same effect. Another group’s results showed that organization was the driving principle.

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For me, the top takeaways from the session were:

  • Don’t be surprised how quickly a group of individuals with completely different backgrounds and experiences can coalesce to get a job done.
  • Innovation takes a cross-disciplinary team.
  • Making sure the right stakeholders are involved at each step is important, and consider that stakeholders aren’t necessarily decision makers, but they can also be people who need to be informed about the project.
  • The more time you spend in the first part of the process the easier the actual implementation
  • Conferences need more interactive sessions like this but it would also be an easy activity for a team within a health system

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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Breaking Bad Healthcare: The Story of Healthcare.gov

It’s generally a good principle to not criticize something if you’re not willing to help fix it. That’s what former Microsoft exec Kurt DelBene learned, when he offered feedback on the Healthcare.gov website after its release in 2013, and instead of just providing feedback, he ended up taking the reins to fix the site. At a recent event sponsored by University of Washington’s Foster School of Business, DelBene provided a mini-business case on what went wrong with the project and how his team fixed it. With clarity, modesty, and wit DelBene both highlighted some major flaws in the process and encouraged attendees to consider a stint themselves helping out the government with major technological and business issues.

One of the first problems stemmed from an issue that is far too common in government and business: saying yes to a project before fully understanding the scope. In this case, and internal Whitehouse IT team, essentially signed up to deliver a website with requirements of something like Amazon.com without ever having built something that big. While most of us think of the consumer interface of Healthcare.gov, and the trouble that happened on that end, the actual site is extremely complex in needing to connect to hundreds of insurance plans among the major payers, and also to the IRS to verify income levels. Any facet of the site’s interface, up-time requirements, and integration needs was a daunting prospect, and the original architects didn’t have the full requirements set, and possibly the experience to know what was missing when they signed up.

Next, they chose two inappropriate technologies. One was a semi-structured database No-SQL database called MarkLogic, which they had always wanted to try out. The database choice itself was not necessarily the problem, but trying a new technology where the team did not have prior expertise for a project of this scale is risky and they chose the database without understanding the project specs. The second, was trying to use a flow-charting application that automatically generated screens to design the website. This type of application might be appropriate for an internal process application used by a small number of technical users, but it is not appropriate for a large scale consumer facing website that is intended to reach the general population, including those whose first language is not English or with a wide range of education. Software has not gotten to the point where it can design user-friendly versions of itself no matter what you read about artificial intelligence.

Another major, and widely publicized failure was delegating different parts of the project to at least 6 different contracting firms. No one took responsibility for the overall integration, and the contractors continued to point fingers about whose technology was failing.

These were only some of the problems that DelBene inherited with a hard deadline to launch the site. Other issues in site design included no failover system, no beta testing, and no instrumentation or telemetry to understand where the site might be failing. Within the development process there were also failings, for example no tracking of bugs and how much work was left to do.

DelBene started by listening, and this included to all team members not just senior leaders. Although he had to hit the ground running: briefing the President two days into the job, and famously, exiting a meeting into a closet instead of the hallway.

He then had the team prioritize what could be fixed for launch and what couldn’t.

While the site wasn’t conceived as cloud-based (in fact the original team expected the insurers to install servers in their datacenters to connect with the Healhtcare.gov site), DelBene says it was an excellent candidate for the cloud which would have been more secure and more scalable. The team did rebuild many consumer-facing parts of the site on Amazon Web Services and continued to iterate and test capabilities as the site was deployed by sending some groups of users to the new interfaces.

While DelBene was extremely modest, always citing the team, which included recruits from Google and Facebook but strangely not Microsoft, he did have some very specific advice for how to successfully run this type of government project in the first place.

The recommendations can be summed up as “run any consumer-facing government IT project the way you’d run a commercial software project.” Hire the right team, plan, test, and iterate, hold people accountable, and encourage honesty.

Solutions for Government IT Projects

So much of this project’s initial issues were due to a lack of coherent team, and a lack of experience. Developing internal IT infrastructure and commercial software that is used by millions of people is very different, and requires a different skill set. As well, it requires humility as end-users outside your organization will let you know if something doesn’t work as evidenced by the negative press the original roll-out received.

Opportunties

DelBene, who used to run the $11B Office business for Microsoft, described this experience and work as the most important he’s done, and he ended the session by encouraging the audience of MBA candidates and alumni to consider how they could help the country. New programs like the White House Digital Services and 18F Organizations are specifically designed for people from private sector to be able to lend their expertise to government organizations for short periods of time. Considering that the future of all government transactions is digital, this is more important than ever.

Posted in: Health Regulations, Lean Healthcare

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Looking Outside Healthcare To Teach Physical Therapy Business Practice

Recap from APTA CSM 2015

Speakers:

Beth Davis, PT, DPT, MBA

Zoher Kapasi, PT, PhD, MBA

Physical therapists have many choices on what to do after graduating: research, private practice, join an existing business, hospital in-patient and outpatient, and home care to name a few. Some private practice owners we’ve met are evangelical about getting their peers to think in a more business oriented way, and have even hatched at Twitter hashtag #bizPT to focus on these issues. They would have loved this session from two PT/MBAs from Emory School of Medicine. The session was a brief review of an elite elective course in the physical therapy program at Emory called “Business Management for the Physical Therapist Entrepreneur.” The course teaches a broad understanding of business issues, not the nuts and bolts of running a practice rather skills for problem solving, thinking like an entrepreneur, and applying the same methodology students use for medical cases to solve business cases.

#BizPT Usual Suspects

#BizPT Experts

In the course, students are challenged to solve bigger issues in healthcare like rising costs, poor care coordination, and the increasing demands of an aging population. Instructors asked students to look beyond healthcare to other businesses and apply these solutions to healthcare. To warm up this comparative muscle, presenters shared some famous examples of innovation transfer including:

Students are trained to evaluate three types of business cases in what could be seen as a mini-business school education. They tackle decision cases, problem cases, and evaluation cases. Instructors try to help them translate their medical investigation and decision making skills to these cases, which have direct medical analogies. Students are shown how analysis of both medical and business cases have similar phases of:

  • Examination
  • Evaluation
  • Diagnosis
  • Prognosis
  • Intervention
  • Outcomes

The course also helps students talk with business lingo which can prepare them to work in larger practices and hospitals, as well as provides them with critical thinking and problem solving skills that will help them fully participate in both business and clinical work upon graduation.

Using cases from Harvard Business School, topics cover all facets of business including growth, customer service, human resources, operations management, marketing, and information technology. Presenters provided some strategies for applying these technique in private practice as well using staff training or lunch & learn discussions. For the folks tweeting on the #BizPT hashtag this course is a welcome addition to a physical therapy curriculum and it seems to have benefits far beyond private practice.

Posted in: Healthcare transformation, Lean Healthcare, Physical Therapy, Rehabilitation Business, Seattle

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Wellpepper’s Top Healthcare Blog Posts of 2014

We had quite an amazing year at Wellpepper and are really looking forward to great things in 2015. We’re looking forward to more changes and disruption in mobile health and telehealth, as well as new business models, billing codes, and proof of the efficacy and effectiveness of mobile health.

As we look forward, we thought we’d spend a few minutes to recap our most popular blog posts of 2014. In order of popularity they are:

Misfit Shine

Jewelry? Hmm.

A Tale of Two Sensors: Misfit Shine vs FitBit Zip

Not surprisingly given the hype around sensors in 2014, our post comparing how the two stacked up was our most popular blog post.

The Future of Mobile Health is Like a Warm Marshmallow

We read somewhere that your favorite tweet is not destined to be your most popular. This blog post has a warm space in our heart as it was a surprise to see mobile health as mainstream as a heartwarming Disney film.

Forging Ahead With Telehealth: A Roadmap for Physical Therapists

Our conference recaps are always popular, and this one was especially popular as all healthcare professionals are champing at the bit for billing codes that reflect the innovative new ways they want to practice.

Healthcare Is Part Of Our Supply Chain: The Boeing Company

Boeing is really pushing the payers and providers to deliver cost-effective outcome-driven care, so we are chuffed to see this one at the top of the list. Which other employers are going to take the mantle for 2015?

Post or Perish: Disseminating Scientific Research and the Kardashian Index

This recap of a talk on social media and popularity as important to scientific research made our top 5, and while the advice was great, and the debate on popularity vs credibility is important, we suspect it may have something to do with the mention of the “K” word.

Posted in: Behavior Change, Healthcare transformation, Lean Healthcare, M-health, Rehabilitation Business, Telemedicine

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Healthcare is part of our supply chain: The Boeing Company

The Health Innovator’s Collaborative sponsored by the University of Washington and the WBBA is entering it’s second year and continuing to gain momentum bringing together providers, payers, and health innovators from education, public sector, and industry to discuss hot topics in health. This week marked the second talk in the new season, delivered by Greg Marchand, Director of Benefits and Policy Strategy at The Boeing Company.

BoBoeing is a data-driven company that makes big bets and takes big risks to bring their products to market. This philosophy extends to how they provide employee benefits, and Marchand and team have taken a data-driven approach to healthcare benefits. In the same way that the principles of lean, data-driven decision making, and cost/risk benefit drive decisions across Boeings supply chain, the same rigor has been applied to healthcare benefits. Marchand knows that Boeing’s human resources are a key part of their success and wants to ensure they are working at optimum productivity. The best way to do that is to make sure they are healthy and that they receive the best benefits available. Quality, innovation, advocacy, and service are the influencers of Boeing’s strategy and the differentiators of their benefits.

Boeing made headlines for their “ACO” approach where they contract directly with healthcare providers and negotiate for service and Marchand came to the Health Innovator’s Collaborative to describe how they did it and why this is the model for the future.

Washington Hospitals, Boeing Strike ACO Deal

Boeing Signs Shared Savings Deal With Washington Hospitals

Boeing-Marchand2Marchand kicked off his talk with a personal example of a “defect” in the healthcare system, to his mind a result of healthcare organizations not having a consumer focus. A few years ago, his wife needed to make a doctor’s appointment for their child. She called for an appointment and was told that she could book a time two weeks from that day, which happened to be a Tuesday. Depending on whether you’re going to see a specialist, 2-weeks could be considered an acceptable wait time for an appointment, however, that wasn’t the problem. The problem was that if she wanted to book an appointment for another day, say 2 weeks from Wednesday, she’d have to call back on Wednesday to book it. Marchand asked the audience to try to imagine what might happen to a retailer like Nordstrom if they used this archane booking system for their personal shoppers. The system had a flaw, and it’s this type of flaw that Marchand and team are on a mission to correct.

boeing-marchand4To do so, they have partnered with UWMedicine and Swedish/Providence in Washington State to provide care for Boeing employees. They also rely on Cleveland Clinic as a Center of Excellence for cardiovascular care. While Marchand says that he doesn’t want employees to have to travel for care, he also wants them to have the most effective care, which is what drove the partnership. (You could tell that this statement was specifically aimed at attendees from the event’s host: the subtext being that it was possible for them to win this business for Boeing.) Boeing’s “triple aim” is quality, experience, and cost with the goal of improving the employee experience and passing any savings as a result of the new ACO model onto employees. Their expectation is that healthcare partners have these same goals and the same data-driven approach. The challenge for Marchand is the need to find partners in all states where Boeing has employees. While Boeing has a lot of clout with $2.5B in annual healthcare spend covering 500K employees, they don’t have the same economies of scale in all states based on employee number. (ACOs looking to pilot new ideas and test data-driven approaches should definitely consider reaching out to work with Boeing: they are looking for solutions.)

Finding the Defects

Marchand’s focus is on continually improving defects in the system and that includes the patient/provider relationship: making sure patients do what they are supposed to do. It also includes using the appropriate forms of communication and care for the situation. Here he gave two examples: using a house call service from Seattle-based Carena for non-emergency issues, especially with children, and being able to email or text your doctor with simple questions, like how to deal with side effects from prescribed medication. Both of these examples provided a higher level of service to the end-user and also lower costs to the entire system. A Carena house-call is 1/3 of the cost of an emergency room visit and email and texting is more efficient and less expensive than a phone call and most certainly than an office visit.

Understanding Cost Drivers

From all the data analysis, Boeing understands very well where its largest cost drivers are coming from and ways to improve, and from Marchand’s talk it was clear that they were very much in the driver seat in pushing their healthcare partners to innovate. Areas of focus include improving the usability of patient communication tools, managing population health, providing easily actionable data for the clinical team, and using the most appropriate and cost effective methods for care. Marchand gave the example of how incentives need to be better aligned to spend money on physical therapy rather than back surgery: again a situation where the patient experience is dramatically improved and costs are lowered, however incentives must be aligned because today, hospitals make more money on surgery than preventative care. Boeing and the ACO vision of the future changes that of course.

The Q&A portion of the event was quite lively and extended far beyond the allotted time. One notable question was about why other employers are not taking the same approach as The Boeing Company. Marchand wishes they would but acknowledged it’s a lot of effort and certainly the data-driven approach is in Boeing’s DNA. As well, only the largest companies have the resources for this type of undertaking.

If you’re in Seattle and interested in the massive changes coming in health and looking for a community of like-minded people plus lively debate, then we recommend you check out the series. Talks are the first Tuesday of every month. We’ll see you there!

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Lean Healthcare, Seattle, Telemedicine

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White Coat, Black Art

Dr. Brian Goldman, photo source: http://www.cbc.ca

If you’re interested in an informative and entertaining podcast that explores medicine warts and all, we highly recommend subscribing to Dr. Brian Goldman’s “White Coat, Black Art.” Dr. Goldman is a Toronto ER physician and living in the land of socialized medicine with a less litigious population enables him to speak more candidly about taboo subjects like doctor’s errors. That said, the first time he admitted medical mistakes while extremely cathartic for him and his patients, caused a furor in the physician community with concerns about future lawsuits. Interestingly, Dr. Goldman noted that admitting mistakes and apologizing made patients and families less likely to sue.

You can hear about this at “After the Error.”

Another more recent podcast that caught our attention was on Lean Healthcare. (Featured is the hospital I was born in, in Kitchener, Ontario.) Interestingly, only days after the episode was aired the government of Saskatchewan pulled the plug on their $40M lean overall of the system. While some significant quality improvements have definitely resulted from a lean healthcare approach, we have noticed that the expense of lean processes are sometimes prohibitive for initial projects. That is, the people and process costs of lean might make the overall project more effective and efficient but the startup costs are high. Ironic isn’t it? Of course Toyota hasn’t been upholding the quality standards they have been known for recently either. I suppose this is why in software development, lean is also equated with agile. It’s not good enough to look at making sure your processes are effective, you also need to understand how to implement quickly and cheaply. Not an easy proposition.

You can listen to White Coat, Black Art live on CBC and CBC streaming or on demand podcasts on CBC’s website.

 

 

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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Transforming Healthcare Through IT in Washington State

It seems every week there’s another health IT event in Seattle these days and we’re pretty excited about that. The grassroots efforts to build a health community really seem to be starting to take hold.  This week we had the pleasure of attending and presenting about Wellpepper at a Technology Alliance and WBBA event called “Transforming Healthcare Through IT: Investment Opportunities in an Emerging Sector”  held at K&L Gates beautiful offices. The WBBA officially launched their new Innovative Health initiative at the event: they are adding a third focus area to their current biomedical and biotechnology pillars and taking up the mantle of healthcare IT. Given that the lines are blurring between medical devices and mobile devices and software in particular, and that the WBBA are experts in healthcare regulations, this is a welcome move.

The view from K&L Gates Seattle, copyright K&L Gates

The view from K&L Gates Seattle, it was that beautiful this week. Source: K&L Gates

The event was kicked off by Rob Arnold of VantagePoint Investments, who outlined why health IT is so hot right now with a review of a number of trends including patient-centered care and the new requirements of the Affordable Care Act. However, he pointed out that Seattle really didn’t register as a center of healthcare IT investment. San Francisco, New York, Chicago, and even Atlanta and Nashville were far ahead. And yet, as we’ve heard many times we have some of the best healthcare systems in the country and some of the best software developers in the world. What we don’t have is investment, but this event, by bringing together investors, startups, and providers was aiming to change this.

Next up was a panel focused on the landscape of and future of IT moderated by John Koster, MD and former CEO of Providence Health & Services, with panelists Todd Cozzens from Sequoia Capital, Mark Gargett, VP of Digital Integration, Providence Health & Services, and Ralph Sabin from Fortis Advisors. The current state of health IT is not great: 80% of health records are running on a 45-year old technology called MUMPS (ie Epic), and 65% of providers continue to look for cost savings instead of at the $1T opportunity to fundamentally change how we do healthcare.  The current systems were characterized as a “big calcified hairball.”

EMRs need to transform and unlock the data in them to change this system, to be able to be prescriptive rather than reactive, for example, imagine identifying asthma patients and telling them about environmental changes that might impact their health.

All the panelists agreed that the transformation needs to come from within the healthcare system, and cited Microsoft, Google, and GE’s entrance and exit from personal and electronic health records as examples of why technology alone without a keen understanding of the process and system will not effect change.

On the other hand, there are lots of opportunities to fix small problems, for example, patient workflow or outpatient care. However, these incremental changes are harder to predict: it’s easier to see the large scale changes necessary than to fully understand the steps on the road to get there. This may be why the venture money shies away.

The panel also agreed that healthcare is becoming a retail model with patients as consumers driven by both high-deductibles and also expectations from conveniences in other industries. Providence recognized that consumers are increasingly in control of their health decisions and “want to be delighted.” Todd Cozzens from Sequoia predicted the winners would be those who could deliver on a retail experience, and close to or possibly even in a patient’s home.

Similar to discussion we’ve heard at other conferences about the future of healthcare, there was a belief that the fundamental skillset of individual healthcare providers needed to change: in the past remembering a number of facts and applying them in a particular situation was important. With technological advances like IBM’s Watson, computers can do a much better job of diagnosis and the role of the doctor changes to a social role of translating diagnosis into an effective care plan. Or as we’ve heard it characterized: “putting the care back in caregiving.”

Next up Mary Haggard and Joe Piper from Point B Managing Consultants and Capital, showed their “Health IT Landscape Matrix” which was an attempt to characterize Washington’s health IT companies according to the big buckets of Triple Aim categorized as “Creating Efficiency,” “Unlocking the Data,” and “Improving the Delivery of Care.” At the same time they attempted to categorize by the buyer (consumer, employer, provider, or payer), which wasn’t quite as easy and probably reflects the changing landscape of healthcare. What was amazing about the exercise was to see the diversity and number of players in Washington State. This is a great start to hopefully what will become a definitive reference source for the local industry.

Next up were the startup pitches from Corengi, Owl Outcomes, Health123, MedaNext, Spiral Genetics, 2Morrow, CadenceMD, TransformativeMed, and Wellpepper, which ranged from patient engagement to unlocking data genomics to unlocking data in the EMR (not sure which is harder ;)). We’ve been at events with most of these companies before and it was great to hear how they have gained traction and how their businesses and stories are evolving. As a presenting startup, we were happy to be in such great company both with our fellow audience and with attendees.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, Healthcare transformation, Lean Healthcare, M-health, Seattle

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UW Medicine’s Journey To Become An Accountable Care Organization

As part of the newly forming Health IT community in Seattle, the Unveristity of Washington and the Washington Biotechnology and Biomedical Association have partnered on the “Health Innovator’s Collaborative” which launched with a series of seminars on how the coming changes in US healthcare affect organizations and innovation.

Accountable Care OrganizationsThis past Tuesday, I attended a talk by Paul Ramsey, MD, and CEO of University of Washington Medicine entitled “The Transformation of Healthcare: Forces, Directions and Implications.” Despite this lofty title, Dr. Ramsey focused on the nuts and bolts of the new Affordable Care Act (ACA) with specific examples of how UW Medicine is becoming an Accountable Care Organization (ACO).

First off, Dr. Ramsey started with some definitions of the goals of the Affordable Care Act and Accountable Care Organizations. When asked if the ACA is having a profound effect, he stated that regardless of any other measures, the number of individuals who are now insured is significant. Harborview Medical Center, a member of the UW Medicine System that covers a diverse and often low-income population, has already seen a 2% decrease in patients without coverage.

What was striking about the session was Dr. Ramsey’s clear conviction that while the ACA is morally just (we need to stop pricing people out of healthcare) organizations becoming ACOs were currently doing it because it makes human sense, while not currently financial sense. The reason it doesn’t currently make financial sense is that the first ACO contracts between payers and providers are still in negotiation and in the switch between reimbursements for procedures to reimbursement for outcomes providers initially see lower revenues as they decrease the number of unnecessary procedures. In the long run, this is mitigated by getting the right care to patients and by managing population health in addition to individual health

The triple aim of the ACA is to improve experiences for individuals, improve overall population health, and reduce the cost of care: lofty but extremely important goals. While managed care and HMOs were supposed to do this in the 90s, their main failure was having the primary care physician as the gatekeeper to all other services. This did not guarantee that the patient received the best and most cost effective care. Dr. Ramsey contrasted this to the goals of an ACO, where a patient might call a nurse hotline and be referred to emergency, their primary care physician, or receives an e-care visit, depending on which was best for the patient and most cost effective in the long run.

When asked if this model was a capitated model, Dr. Ramsey said yes, but at a population level, and that is why the current negotiations between payers and providers are so important. Providers are choosing which measures they will be held accountable for in their first year as an ACO. UW Medicine is choosing seven disease management measures, three health status and screening measures, and number of caesarian sections, which is apparently a hot button measure for CMS. Because all measures will not be implemented immediately UW Medicine will spend some time transitioning between models, however, this does not mean they won’t continue to improve care in all areas. He cited his own recent experience as a cataract patient at UW Medicine as of an example where high quality outcomes, patient care, and cost-effectiveness were combined.

As a guide for these types of measures, and as an example of the medical profession taking on best practices regardless of financial incentives, Dr. Ramsey cited http://www.choosingwisely.org where each medical specialty association provides their own guidelines for reducing unnecessary procedures and promoting best practices. This is a great resource for patients as well to review whether costly procedures are actually recommended and effective.

Accountable Care OrganizationsThere was some discussion that the US medical system as a whole could decrease costs by 25% without reducing the quality of care. UW Medicine has been able to reduce costs by $90M annually which is only a 2-3% of their operating budget and remain a top hospital. UW Medicine will continue to improve on both costs and their overall ratings.

Interestingly, the most important factor in patient satisfaction, a key health system rating, is the communication with their healthcare provider, rather than the outcomes. Improving patient/provider communication is an extremely cost effective way to ensure great care.

This was a great talk, realistic yet optimistic about the challenges and opportunities inherent in this transition to the new models of care we so desperately need.

The two remaining talks are:

May 13, 2014: “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research”

Larry Kessler, ScD, Chair of UW Department of Health Services and former Director, Center for Devices and Radiological Health, FDA, will consider the coming necessity for innovations to demonstrably provide value and how the experience with comparative effectiveness can help innovators gather the needed evidence.

June 3, 2014: “IT can make a big difference in health: Why hasn’t it?”

Peter Neupert, Operating Partner of Health Evolution Partners and former VP of the Health Solutions Group at Microsoft will draw on his extensive experience with both institutional and consumer aspects of health IT to consider the enormous potential and serious pitfalls that make this area of innovation so challenging.

Editor’s Note: The primary care physician as gatekeeper is a failure in the single payer system as well. It denies patients access to the care they need and also adds waste into the system. In Canada for example, a referral to a specialist must be done by a primary care physician and expires every 6 months. So, if a patient has a chronic disease that they need to see a specialist for, the patient cannot keep seeing that specialist without getting another referral, even if all parties agree the patient should keep seeing that specialist.

Posted in: Health Regulations, Healthcare Disruption, Lean Healthcare

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Just-In-Time Management Principles for Physical Therapy

Disruptive technologies and business models, paired with changing consumer expectations, will change healthcare.

In keeping with our theme of lean healthcare, today’s topic is a recap of the American Physical Therapy Conference CSM 2013 is a session called “Doing Today’s Work Today: How To Reduce Inefficiencies in Physical Therapy Service Delivery Through the Application of ‘Just In Time’ Management Principles.” Yes, the title was quite a mouthful, but the session was well organized, clear, and straightforward. Presenters Todd E. Davenport, Nicholas J. Ferlatte, Ivan Matsui, Carol Jo Tichenor, were all from Kaiser Permanente. Since Kaiser Permanente is a managed care consortium, they are able to experiment with programs and collaboration between disciplines all within the umbrella of their organization.

Starting with a recap of lean management principles applied to healthcare, presenters focused on case studies and learning from three programs at Kaiser, all designed to increase client satisfaction and decrease waste.

Roving physical therapists program

This program had physical therapists ‘on-call’ to be brought in if a consulting MD needed support. The therapist could quickly access the situation, make a prescription, and then decide whether the patient needed a referral. If the patient needed a referral to a physical therapist, they might have to wait 30 minutes to see that physical therapist rather than a few weeks. The results of the program were significantly happier patients, and a dramatic reduction in the wrong physical therapy prescription. Given that patients were seen sooner, there could also be assumed to be better recovery times as well.

While this program turned out to be the best for patients, some considerations needed to be taken on how to manage the physical therapist’s productivity. Kaiser’s structure of being a full-service managed care organization enabled this scenario, but it’s definitely worth considering how to bridge this gap with integrated care.

Telemedicine

Telehealth is expected to grow 55% in 2013 and reach 1.8M patients. This is partially driven by Medicare’s penalties on readmission, but also as Kaiser Permante learned, by consumer preference. Patients liked the video check-in because it meant they didn’t have to leave work or battle traffic for their appointments. There was also a strong personal connection having the appointment at their convenience and location rather than a clinic. However, one extremely important reason they liked the Kaiser program was that it was free. This is a consideration that’s not possible for many clinics. However, we have seen changes in billing codes in most states that allow for telemedicine.

Patients Preferred Communication Modes

Patients Preferred Communication Modes

The presenters also shared some best practices if you’re thinking of implementing video visits into your practice which we’ll dedicate a separate post to in the coming days.

To judge whether telehealth is effective, you need to consider two factors: clinical outcomes and patient satisfaction. If you’re going to try a telehealth pilot, think about how you will measure in advance.

Workplace occupational injury prevention

Workplace injuries are decreasing, while workplace injury costs are actually increasing. That is, fewer people are being injured but it’s costing more to treat those injuries. The main users are younger men who work as laborers, and women 50-60 who work as tradespeople. Similar to other sessions, this session promoted physical therapists as ambassadors of total health and wellness, and in this case occupational wellness.

Kaiser Permanente implemented an occupational wellness program in their own workplace in two high-injury departments: radiology and materials management. Starting with an ergonomic assessment, they then created programs that include pre-shift and at-home exercise programs, and stress and weight management. The result has been a steady decline in workplace injuries over the last 15 years, and a general increase in the importance of health and safety.

While this program was internal to Kaiser Permanente, corporate wellness programs are quite common with their focus on preventative healthcare. This could be an interesting area of focus for physical therapy organizations.

Finally, the panelists encouraged the audience to start thinking about and embracing new business models by saying “It’s okay to ask for money for services provided.”

Posted in: Lean Healthcare, Rehabilitation Business

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Learning about Lean Healthcare at APTA CSM 2013

We’re just back from the American Physical Therapy society Combined Sessions meeting in San Diego. How lovely, you say, San Diego in January. We think it was lovely but we spent most of the time in the convention center meeting people, and soaking up all kinds of information. Over the next few blog posts, we’ll go into detail about a few of the sessions.

One of the most interesting, was Lean Physical Therapy presented by Proaxis Therapy, a 20 location organization serving South Carolina and Colorado. Team members from Proaxis had completed the Belmont University Lean Healthcare certificate, and were sharing how they used these practices in improving their organization. Lean Healthcare comes from Toyota’s famous Lean Manufacturing philosophy. Wellpepper is following Lean Startup techniques so we were extremely interested to see how this could be applied to healthcare. Lean philosophy looks at eliminating wasteful efforts and continual improvement.

Lean Healthcare Observation sheet

Lean Healthcare Observation sheet

The session started with a video of a physical therapist at a Proaxis clinic running around trying to start a session with a patient, looking for equipment, trying to find gloves that fit, and muttering under her breath. The patient, meanwhile, was waiting on the table. A great thing about this session is that it was interactive, and we used this video to start our own lean training, first by practicing the art of observation. We broke into groups and watched the video again, focusing on observing waste. We tracked how many steps she took (120-150), how long it took before she got back to the patient (almost 5 minutes), what activities she did (see image), and how many times she retraced her steps (a lot).

Proaxis had done the same observational activity, and talked about how they used it to cut waste: organize supplies better, make each PT accountable for all the supplies, and completely reorganized the clinic layout based on user tasks.

From a software perspective, it was pretty fun to experience this type of usability study in the physical world.

IMG_0283

Lean Healthcare Value Map for hand washing

Next we learned about value stream mapping: breaking down an activity into it’s component tasks, and looking for tasks that are waste, versus tasks that add value for the customer. (All of lean is focused on adding value to the customer.) Here’s a value chain for hand washing. You might not think of this as a valuable task, but it keeps everyone healthy.

In this value chain, not being able to turn the water on is waste. There are other potential areas for waste, for example, maybe the soap or paper towels are empty. All of these take value away from the patient, and frustrate the caregiver.

Again, we practiced this by trying to map out the value stream for what seemed like a simple task: patient cancelling an appointment. Our small group very quickly realized that there are no simple tasks as we got into a complex decision tree about whether this was a chronic canceler or an isolated incident.

Our value map became quite messy.

Lean Healthcare Value Map Exercise

Lean Healthcare Value Map Exercise

Next step was to ask the 5 Whys, a series of 5 questions designed to get to the root cause of an issue. We figured out that the root cause on this problem was wanting to make sure that physical therapists were being as productive as possible, and scheduling was a key part of this. Although, at this stage you’re not supposed to problem solve, our little group discussed briefly how airlines solve this type of problem by overbooking.

When we came back together as a full group, Proaxis Therapy shared a few case studies on how they had implemented these techniques in their clinics in two key areas: reception/registration, and documentation.

Lean Healthcare Case Study Results

Lean Healthcare Case Study Results

The results were pretty amazing, especially in the area of documentation, saving physical therapists 2 weeks a year, and they had feedback that could really improve their EMR system. For lean software companies, having a user do this type of analysis would be invaluable.

This blog post only scratches the surface of the session, and presenters Sean Mc Enroe, Robbie Leonard, Nicole Kluckhohn, and Shannon Irish reminded us that they were distilling a 5-day course and months of work into 2 hours. They did a great job of it!

Posted in: Lean Healthcare

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