20 February 2015
Dear Interested Readers
Inside this Weeks Newsletter
The letter gets a new name this week: “Healthcare Musings” and may look a little different but inside things are still produced by the same “standard work”. My thinking about healthcare this week emerged from two sources, a letter that I received a few weeks ago from a patient that I have known for many years and a trip that I took to New York. It is a continuation of healthcare musings about the future and the process of change in healthcare.
I hope that you are getting into the habit of a regular visit to strategyhealthcare.com where you can read edited bits and pieces of previous weekly letters. Thank you for your continuing readership and the comments that you send me.
Will Innovation Help Return Joy to Practice? Or What I Learned on the Subway.
My wife and I spent this frigid past weekend in New York City. We were there to visit our youngest son and his fiancé and to meet her father who drove down to join us from the small town in rural northwest Connecticut where she grew up. I have spent most of my adult life trying to avoid New York, although I do have some significant New York memories. My first trip there was in 1956. Shortly after we came through the Lincoln Tunnel into midtown Manhattan, we were stalled in the traffic that never goes away. I was excited by the amazing scene and was trying to take in all the new sights and see the tops of the huge buildings that formed the canyons through which we were making little progress. While my parents were busy dealing with the stops and starts of the traffic, I was leaning way out of the back window of our new ‘56 Ford station wagon that bore Texas license tags. My head was cranked around as I was trying to get my first glimpse of the iconic image of the Empire State Building. A man on a nearby curb yelled out with the first New York accent I had ever heard, “Hey Tex, betcha don’t have anything like this back home on the range!”.
We had driven north from the Carolinas on a side trip from our annual visit with my grandparents. We began on the Blue Ridge Parkway and then swung across Virginia to check out Mount Vernon and Washington, before heading to Harper’s Ferry, Gettysburg, Valley Forge, Philadelphia and as many of the other Civil War and Revolutionary War battlefields as possible. I was into history and was collecting postcards and maps from all these sites.
It was a whirlwind trip with an aggressive agenda and probably a shoestring budget. I suspect that my father did not want to pay New York City hotel rates so we attacked the city from a small local motel in New Jersey, which meant that we were part of the early commute into Manhattan. Dad’s plan was that we would spend one day in the city. We would get an overview of the city from the top of the Empire State Building and then circle Manhattan on a Grey Line cruise before finishing off the day’s experience with a visit to Coney Island. It was a great plan and a day that I will never forget, but it left me with a sense that you always approach New York for a specific reason and with a plan to avoid expense while keeping your wallet in your front pocket to avoid theft.
Most of the time I treat New York as a barrier for me to avoid by land or by air. Over the years I have driven out of my way trying to get to the south without going through the city. I will go far to the west of the urban mess at someplace like Port Jervis or at the least, the Tappan Zee Bridge. If I have to go to Gotham these days, I usually take the Acela. Long ago I began to call the huge vertical housing complexes, both public and private, that I would see as I traveled close to city, “human file cabinets”. I have great empathy for those who must live in close quarters and relative anonymity in that environment. I do not think that I could ever do it. I imagine that their next step is permanent residence in one of the enormous cemeteries that roll endlessly to the horizon at various points along the heavily congested interstate and other highways that are euphemistically referred to as “parkways”.
Almost all of my positive memories of New York relate to my family and marathoning. The 1977 New York Marathon was the first marathon I finished. I had bombed out trying to run the Boston Marathon six months earlier that year. It had been one of those hot Patriots’ Days and I had died at mile 18 after running too fast at a pace well below a 7 minutes a mile while ignoring the advice of more experienced runners. New York was my “countermeasure”. It was a chance to exercise the wisdom of “Start slow, then slow down”. On that leisurely jog, I got a sense of the size and diversity of the city and just how big Brooklyn is. The borough seems to go on forever, from the end of the Verrazano Narrows Bridge to the Pulaski Bridge. Half of the New York Marathon is in Brooklyn!
My oldest son lived on the upper East Side as a young Skadden, Arps lawyer in the early nineties and then returned after a stint teaching at the University of Miami to much less luxurious circumstances on the upper West Side while getting an advanced law degree from Columbia. During his time in the city, we did the Marathon several times. Now my youngest son is a graduate student at NYU and commutes to Washington Square on the “N” and the “R” trains from Brooklyn where his neighborhood is an ill defined area between 4th Avenue and the waterfront. He lives at the intersection of Park Slope, Gowanus and Sunset Park, in the “y” between the elevation of Interstate 278 and the Prospect Parkway.
Except for the route of the Marathon, Brooklyn is a new experience for me. I was surprised to see that my son’s apartment is just a few hundred yards from the ten-mile mark of the marathon as 4th Avenue crosses 17th Street. Who knew in 1977 when I first passed that way, almost eight years before he was born, that I would ever return to those neighborhoods for anything other than another run?
On Sunday evening we braved the extreme cold and even lower wind-chill equivalents to go to a show in Manhattan. Huddled in the relative warmth of the “N” train, I realized that healthcare advertising surrounded me. There were warnings in English, Spanish and Chinese to remind everyone that the open enrollment period for the healthcare exchanges ended at midnight February 15 which was just a few hours into the future. The ads made me hope that everyone who needed to exercise that option had taken advantage of the opportunity. After switching from a local “N” train to an express “R” that would speed us quickly to Times Square, I noticed that one entire side of the new car was a repetitive add for a mental health provider, “Talkspace”, suggesting that you could download their iPhone or Android app and along with 70,000 other stressed souls be getting unlimited texting with a licensed mental health worker as treatment for your anxieties and other issues as you’re working your way through the subway system to wherever you are going.
I have been meaning to talk for sometime now about the interface between smartphone technology as demonstrated by the Talkspace ads and medical practice. My most important reason to write is that I think that there is much to explore in terms of the opportunities that mobile devices offer for innovation and practice improvement as a benefit for both patients and clinicians. I am convinced that a more effective integration of these technologies into practice is inevitable and will improve the experience of care for patients and clinicians. This technology should be a huge benefit in our quest for the Triple Aim. It amazes me that there are still barriers to the effective use of these technologies and that many of those barriers are financial and cultural in origin but more about that later.
My impression was underlined recently when I received a letter from Alan Gaynor, emeritus Professor at the Boston University School of Education who is an old friend and patient whom I saw for over thirty years (and has allowed me to describe the richness of our relationship). Over the years, Professor Gaynor was one of those patients whose name, when it appeared on my schedule, always caused me to smile in anticipation. I should have paid for my visits with Alan. He challenged me and demanded that our relationship meet his needs. His questions frequently sent me looking for answers and his dedication to fitness and self-care long preceded the current rage for Fitbits. Like Barbara Mandrell, who once crooned, “I was country before country was cool!” Dr. Gaynor was focused on fitness and self-care before fitness and self-care were cool.
Now, Alan, like me, is retired, and has more free time to read and think, but he has not withdrawn from the world nor has he changed the way he remains active and interested in solving problems. Just as I have been interested in systems thinking in healthcare, Alan has had systems thinking interests in education and remains active in academic circles. One of his interests is computer simulation modeling for insights into solutions for the many problems that face education. He will be presenting a paper at the 2015 Annual Meeting of the American Educational Research Association in April entitled, “Development Toward School Readiness: A Holistic Model.” A previous paper (2012) was entitled, “Different Students: How Typical Schools are Built to Fail and Need to Change.”
When Alan wrote me, he might not have known that for a long time I have been interested in the similarities associated with planning for the future in healthcare and in education. I think that in both arenas there are issues of urgency and social justice that are absolutely similar as well as the similarities they share in the concerns about sustainable finance, regulations, quality, and effective management. I do not think that one exceeds the other in importance and that universally high quality healthcare and education are absolutely necessary for a future with any real positive possibilities for all of us. It may be easier to solve the problems of healthcare and education simultaneously than separately. Both are plagued by local variations in the willingness to invest collectively, controversy about what is important, and the antics of political demagoguery. Public private partnerships have been offered as “solutions” for both.
Alan sent me his thoughts about technology and healthcare from his perspective as a patient along with some compliments about the care he has received over the years at Harvard Vanguard and an article by Eric Topol who is now at the Scripps Clinic after many years at the Cleveland Clinics. Dr. Topol has shifted from a focus on issues of cardiology, where his career started, to becoming an articulate futurist and advocate for the effective implementation of technology to support better care at a lower expense. Here is Alan’s letter:
Hi, Gene. I hope this finds you well.
I have been doing a bit of reading on the future of medicine. I started with “Cell” by Robin Cook, which a friend recommended to me. I then read Eric Topol’s “The Creative Destruction of Medicine” and a number of his recent articles (see attached, for example). I just ordered “The Patient Will See You Now: The Future of Medicine is in Your Hands” for my Kindle.
While it appears that rapid change in the medical field is just beginning (beyond the organizational changes that, while continuing, are in some ways “old hat”), I am impressed in thinking about how far Harvard Vanguard came under your leadership of Atrius Health. While it appears that momentous further changes—especially in the individualization of medicine and of doctor-patient relationships (again, see attached), my sense is that Harvard Vanguard came a long way in the development of collaborative relationships among physicians and between institutions (e.g., Harvard Vanguard and Beth Israel Hospital) and, very importantly, in the development of inter-physician and inter-institutional information systems to support these collaborative relationships. As a patient, for example, my doctors have for years had mutual access to my medical records, to which I also have considerable access, including test results, and I have encrypted e-mail relationships with both my PCP and specialists, including records of medical treatment at both Harvard Vanguard and Beth Israel Hospital.
I have thought about these issues for a long time; however, I have been focusing recently particularly on the future of medicine as it is being affected by the “I-Phone Revolution,” in much the same way that the religious priesthood was affected by Gutenberg’s invention of the printing press and the subsequent “democratization” of biblical knowledge and interpretation. In the Christian world, this led significantly to the Protestant Revolution. In the current world, an important aspect of the revolution in information technology lies in the development of medical sensor devices and in the means of communicating and analyzing this huge data-base at both the individual and population (“big data” in “the Cloud”) levels.
My sense is that your leadership was very much consistent with—and took advantage of—the changing technology of your time. I view that with great admiration.
If you have a subscription to the Wall Street Journal, you can read the article Alan sent me at:
If you do not subscribe, try this video from Brian Williams and Nancy Snyderman. It is an interview with Dr. Topol telling the story that he wrote in the article. The video says a lot in less than nine minutes.
Topol goes beyond the “gee-whiz” of technology and makes a couple of excellent points that Alan has echoed. He recognizes the waste in current practice patterns and the possibility to use smartphones, sensors coupled with smartphones and handheld technology to reduce imaging and lab costs. As an aside, for several years I have owned devices [from Withings] to measure my weight and BP that record the data on my iPhone and that will email the data to whomever I wish, including my doctor. The expense was about $300. I used the technology to follow my mother’s BP and weight from a thousand miles away before she died.
Topol points out that automated data interpretation can be used to leave the doctor out of the loop in self-management of chronic medical problems. One goal that I always had with my patients who had a chronic disease was that they might be able to use their time with me to increase their self-management capabilities to a level that they rarely needed much more than advice from me. That will be the future. I think that Alan and Topol see doctors and patients redefining their relationships around the new technologies, just as priests and parishioners did around the interpretation of the scriptures after Gutenberg made the Bible widely available.
Effective self-management of chronic disease is one of the best strategies for reducing hospitalizations and readmissions. These admissions for failures of care in ambulatory sensitive chronic disease management represent about 50% of all admissions. That is a huge opportunity! Appointments for chronic disease management are a huge source of revenue in the current economy of practice, but in the future will be treated as a source of cost and we will be reducing them just like we try to reduce hospital days through reductions in admissions and readmissions now. In both situations patients are benefited by enjoying better health without the expense or inconvenience of going to the hospital or the doctor’s office with the frequencies that “good care” forces them to go now. The advantage to the system will be that rather than having a shortage of clinicians as more and more people have access to care, physicians working in new configurations with technology and in more collaborative relationships with better informed patients should have more joy from practice and be able to better serve more patients.
The alternative is unacceptable. SG2 a Chicago data and management consulting firm for health systems predicted 7 or 8 years ago that by the year 2020, now less than five years away, there will be one PCP for every 10,000 American adults. That fact alone calls for redesign and redeployment of medical process and the clinicians who work in them. That is not a problem, rather it is an opportunity since it was reported this week that physician “burnout” was up 16% in 2014. Rising patient demands for service in a resistant system is like trying to put traffic through the snow clogged streets of Boston. Years ago Mayor James Michael Curley commented on snow problems with, “God sent it. He can take it away!” The snow will eventually be going away and as frustrated as Governor Baker and the citizens are now, we all know that by Opening Day the snow and its associated problems will fade into the folklore of the winter of ’15; but healthcare issues will not solve themselves. God will not take these issues away, but perhaps the market will.
Talkspace is one innovation. There is also Zipnosis, “Online diagnosis and treatment in minutes” and then there is the whole wide world of video visits with providers like American Well. Check them out. They did not start yesterday and they have been quietly learning how to capture more and serve more and more of the patients as they capture revenue that our “standard” office practices and health systems can not survive without. Learn more about them.
A story that I frequently told my chronic disease patients (about 90% of my practice was with patients who had DM, COPD, CAD, CHF, cardiomyopathies, arrhythmias and valvular heart disease) was the story of the interview between an elderly Dr. Oliver Wendell Holmes and a young reporter from a Boston newspaper of the 19th century. The good Dr. Holmes was a renaissance man of medicine and letters and was the father of the long-lived Supreme Court Justice, Oliver Wendell Holmes, Jr. who served on the court until he retired at age 91. He then lived to within two days of his 95th birthday. Holmes Senior was one of Boston’s most respected physicians and intellects of the mid 19th century. He was a physician contemporary of Emerson. The cub reporter that had arranged the interview with the octogenarian Holmes asked, “Dr. Holmes, based on your experience as a physician [We might assume he was thinking, “…and your own advanced age”], what advice would you give a patient who wants the secret to a long life?” Holmes stroked his beard in contemplation and then said something like, “I would advise them to get a chronic medical problem and take good care of it!”. The benefits of successful self-management have been appreciated for at least 150 years.
Some of my readers will remember the story of my first experience with the iPhone app era of self-management. I have mentioned it before but it bears repeated. The story occurred after I had given up most of my patients, as I became CEO of Harvard Vanguard and Atrius Health in 2008. About a year later I received an email from a former patient who was an overweight, diabetic, hypertensive software engineer in his late 30s. His father and mother were also my patients and his father was diabetic and hypertensive but was athletic and not overweight.
I had been convinced that the best strategy to control the son’s cholesterol, A1c and blood pressure had to include substantial weight loss. His weight was over 300 pounds. I had tried everything I could think of to help him with his weight control including a joint visit with his wife who was equally frustrated and worried, and eager to do anything she could to help.
My patient’s email requested that I reorder some of his routine lab tests. He also asked if there was any way that I could see him. In Epic I discovered that he had been lost to care except for prescription refills, so I wrote back and said that I had placed an order for follow up tests and that I would see him after the results were available. I was still seeing patients, some like him, in a “shared medical appointment”, once a week late in the afternoon at one our sites near my administrative office. He replied that he did not want to come to a group visit so I agreed to come over early and see him alone before the group visit.
My first surprise came when I got back the lab results. For the first time ever the results were normal. My second surprise came when the medical assistant handed me the form after she had weighed him and put him in a room. He weighed 195 pounds which was pretty thin given that he was about 6’3” tall and had a large frame. He had lost over one hundred pounds. His BP was low, around 100 systolic. When I walked into the exam room my patient had a big smile on his face. He handed me his iPhone with an app called “Lose-It” on the screen and then explained how he was using it to monitor his diet and exercise. His chief complaint for the visit was that he was frequently light headed. Solving that problem was easy because he was still taking most of the blood pressure meds that I had been giving him when he weighed over 300 pounds. My first thought was, “In the future who will really need a doctor?”
We will need doctors but we will not need them to do what they spend most of their time doing now. The problems for the future do not lie with the technology or with the patients. Patients have many valid reasons to use the technology. First, the results with the new apps may be better for some problems than the traditional office visit, since they promote self management. Second, going to the doctor is very inconvenient for many patients. They really have better things to do, like go to work. I recently talked to someone who is hypertensive but well controlled on low dose hydrochlorothiazide, with weight loss and improved exercise habits. This person is required by his doctor to come to the office every three months for a BP check before she refills his prescription. What is that about? No matter what the motivation, it is a waste of time, even though the office visits are all covered, except for a small co pay. Thirdly, using office visits for care that can be provided in a virtual environment represents poor utilization of scarce resources, appointment time and expensive office space, when there are so many patients who have no access or difficult access to care.
So why don’t we see a rapid increase in the use of these new technologies? I think we will. Like the lazy river in last week’s letter, things will begin to change fast. Venture capital, subway ads, better and better technology, disruptive innovators who want their day, long waiting times for appointments; all of these things will merge to change the way primary care works in the near future and the speed with which the changes occur will surprise many, just as we are often surprised by the explosion of a flare of a chronic disease which looks like a new event but is often just the sudden and dramatic awareness of a chronically undermanaged problem.
There are other reasons that many clinicians and systems are ignoring the problem. Virtual care requires skills that need to be taught and clinicians are so overworked in the current failing systems that there is neither time nor the financial resources for the transition. It is also true that most compensation systems do not know how to value this new work, although they are quite comfortable still providing compensation for care that provides no value. Finally, there are the issues of adaptive change. We must really reorient ourselves to new ways of thinking about how we practice and those changes are resisted with emotion even if they are necessary, inevitable, and will eventually be beneficial for everyone.
I know that in many places serious work is being done to resolve these concerns and create the new systems of care. At Atrius Health, Harvard Vanguard is investing significant resources to create a new practice model. They are using Lean thinking to guide their process of innovation and presented some of their work at a Simpler sponsored program last October where other groups like Kaiser presented their efforts to innovate with new processes and approaches to care.
There is a simple way of thinking about enterprises. They all have only three components: assets, processes, and outcomes that we call products, services or missions. Assets include everything, including people, that are used to configure the processes that produce the products and services, or achieve the mission. These new technologies are new assets. We are in a period of reconfiguring all of our assets into new processes of care and should surely expect that these technologies and the relational changes between clinicians and patients that they will facilitate, will offer us new opportunities to improve the products, services and missions of our enterprises. It should be an exciting time full of great expectations.
I have been to big cities in far away places. Some like Beijing and Shanghai are larger than New York but I do not relate to them the way I do with New York’s concentration of lives that seem more like my own life. Perhaps this is what evolutionary psychologists call “kindred” feelings. Perhaps that kindred feeling is the origin of my empathy for our cities that seems more proximate to me than concerns for others in more distant places. As I rode the subways, looked at the tall housing complexes that resemble file cabinets or drove past acres and acres of headstones, I wondered, how do these people get the care they need? I know part of the answer. I have visited New York Hospitals. The public system of hospitals is enormous. The usual costs for care are high in suburban communities and the challenges to the delivery of care are huge in our rural communities, but those costs and difficulties must be greatly enhanced in our largest cities where the problems of providing care are complicated by the other social issues that plague the city’s underserved.
Dr. Patty Gabow showed the great benefit of Lean in an urban safety net system at Denver Health. I know that the New York Health and Hospitals Corporation has been using Lean for several years to improve care at the network of public hospitals and clinics in New York. I also know that Lean has tools and a philosophy that will be beneficial in reconfiguring care processes to take advantage of what the new smartphone technologies offer.
Most of these thoughts had come and gone before we got to Times Square but returned for more focused consideration during my walks in the snow far away from the city in my little New England town. New York always stresses me but I usually learn something and enjoy talking about it from the safety of my small town, population 4,397. It must now be 4,399, since my wife and I arrived. Things are changing everywhere.
Only 52 Days Till The Home Opener. How Long Till the Snow Is Gone?
Today as you read these notes the Red Sox pitchers and catchers are having their first official team workouts in Fort Myers! You can see the entire Grapefruit League schedule for the Sox at:
By the time the Sox come to town for their first game against the Washington Nationals on the 13th of April they will have already worked their way up the coast playing the Phillies and the Yankees during the previous week. I guess the big question is whether the snow will be gone when they arrive home.
I am beginning to have spring thoughts. As I was jogging along by the lake in a snow squall, looking out over the ice at a small ice fishing shack parked over a part of the lake where I have caught a lot of fish, I started thinking about “ice out”. It was mid April last year; mid March the year before. No year is the same as the one before. I am hoping for a reversal of fortunes from current experience and would love to be surprised by an improbable March ice out. Why can’t it be just as unusually hot in March as it has been unusually cold in February? They say global warming is about unexpected wide swings in temperature. Anything can happen and probably will. If you take your walks this weekend in cold weather, just keep thinking that it is only a month until spring. You, like James Michael Curley, can bet on the fact that the ice and snow will eventually melt, just as surely as the Sox will return from Florida about that time.
GeneDr. Gene Lindsey