June 14, 2024
Dear Interested Readers,
Reflections On This Moment In Healthcare
When I began to write these Friday letters sixteen years ago in mid-February 2008, it was much easier than my task now. All I needed to do then to discover plenty to write about was to get out of my office and walk around. Employees were delighted to see me and would begin to tell me about something exciting that was happening in their unit, or they would tell me about a problem that concerned them. All I needed to do to put out a letter was to report what I had been told by the people who were in direct contact with our patients or to listen to the feedback from the patients that I continued to see.
In Lean philosophy, the person who does the work, or interfaces with the customer, and not the middle manager or the organization’s top management, is the most reliable source of ideas that will lead to innovation and continuous improvement. I believe that principle is as true in healthcare as it is in producing cars or appliances. At this moment in healthcare, I wonder if the enthusiasm for the Triple Aim or the focus on continuous improvement in the six domains of quality– patient-centeredness, safety, equity, efficiency, effectiveness, and timeliness of care–articulated in Crossing the Quality Chasm (2001) are still driving efforts to improve the cost and quality of care everyone can access. Now as a consumer of healthcare services and not as a provider, I wonder whether or not the stresses in our society have stalled the widespread efforts at improvement that were once so exciting for me.
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These days I find the fodder for many of these notes in publications which means that I am not speaking as an active participant in the improvement effort. I consume the output of others that I find in The New England Journal of Medicine, or in the publications of the Commonwealth Fund, the Kaiser Health News Service, the IHI, the Milbank Foundation, and the Robert Wood Johnson Foundation. I get the healthcare perspectives of journalists and pundits from newspapers like The New York Times and The Washington Post with the same relish that I once reserved for the sports pages of The Boston Globe, and publications like Sports Illustrated, and Runner’s World.
I feel my reading keeps me mostly up to date with what is happening on the frontiers of healthcare delivery, healthcare policy, and the expanding issues of healthcare equity and the social determinants of health, but what I usually offer you these days is second-hand analysis filtered through a hands-on experience that ended over a decade ago. I am now an outsider looking in and not an active participant in the front-line effort to achieve the Triple Aim and true equity in healthcare. What I hope this letter begins is a new direction where I am often writing from the perspective of a healthcare consumer. I hope that my perspective as a consumer of healthcare efforts will be enhanced by my prior experience as a provider of care and as a former healthcare manager/ executive.
This week my wife and I attended a luncheon in Rhode Island that was the 60th reunion of the class of 1964 of Pawtucket West High School. As you might imagine the list of known members of the class who have “gone on to their reward” was close to 25% of those who graduated. It would also not surprise you to know that much of the conversation was about medical experiences, good and bad, and opinions about the current quality of healthcare. My stories were not unique. Everyone, or at least many of the 77 and 78-year-old attendees, that I spoke to at the reunion had worries about the cost, access, safety, and overall quality of their healthcare. Everyone knows we have problems. What amazes me is that it has become a reality that healthcare has problems that most people accept because there is not much most consumers feel they can do to improve their experience of care.
I want to be balanced in my review of the care I receive and the function of the organizations where I get my care. In this letter, I will begin with an overview of where I now get my healthcare. In time I will register my complaints, but I will begin with an attempt to focus on what is working well. I have no complaints about the professionals and support staff that provide my healthcare. My concerns lie with the systems within which they work, and the challenges that face those systems and their consumers. My greatest concern is for the uneven distribution of access and the continuing inequities in care delivery that most significantly impact disadvantaged populations and individuals.
Ten years after retirement and living a hundred miles from Boston,I still get much of my healthcare from what were once Harvard Vanguard sites where the signage proclaimed that the practice was affiliated with Atrius Health. These days those signs have been further altered to say that Atrius Health is part of Optum Health. Optum is the medical practice part of United Health Care which is the second-largest health insurer in America by membership and the largest by revenue. Atrius assured its access to capital by selling itself to Optuma, a for-profit healthcare provider. Ever since the sale, I have been looking for evidence of change. It has not been long since the new owners took over, and so far I have not noticed anything negative that is obvious to a consumer. It gives me great pleasure when a lab tech or receptionist who has worked for Harvard Vanguard recognizes me and reports that they miss me and remember the efforts that I made to improve their work lives.
I enjoy getting my primary care and dermatology care at the Wellesley offices of Atrius. As one Interesting twist, my PCP works from home in Western Massachusetts and our contact is primarily through the “My Chart” function of Epic’s automated medical record. My physicals are done by the nurse practitioner who works with her. During COVID, I would have video visits with my PCP but since the pandemic ended, practice across state lines is not allowed.
Most of my prescriptions are sent to me by mail from the Wellesley site pharmacy. I call one day for a refill and like magic the meds appear in my mailbox the next day. It feels like a miracle and the call usually takes less than two minutes. This pharmacy service began while I was CEO, and we used Lean principles to make the pharmacies more efficient.
My dermatologist is also at Wellesley and the continuing relationship is well worth the two hundred mile round trip effort to see her. I have had over twenty basal cell and squamous cell tumors removed. I guess I am a garden of skin cancers because as a child in the South and Southwest, I wore no shirt and only shorts from May through August. As an adult, I logged many miles running without sunscreen while wearing only shorts and a skimpy singlet.
I often have my lab tests done at Wellesley or at the Chelmsford offices of Atrius where I also see my excellent neurologist. The round-trip effort to get from my home in New London, New Hampshire to the Chelmsford office is only one hundred fifty miles. My colonoscopies, MRIs, and other high-tech diagnostic procedures are usually done at the Kenmore Center in downtown Boston. I trust the quality and remarkably the cost and therefore my portion of the expense is less by far, so far, at Atrius than in New Hampshire where much of the outpatient testing utilizes for-profit providers.
I have begun to get surgical care and podiatry at Dartmouth Health. What has amazed me is the integration of my Atrius and Dartmouth Health records through the Epic medical record. MyDH is what Dartmouth Health calls its version of Epic’s MyChart. The Atrius version of MyChart is called MyHealth. Information like lab tests, appointments from the past, and those scheduled for the future from both organizations are seamlessly integrated when I log onto either MyHealth or MyDH. I believe that Epic may currently be for patients the single most positive aspect of the effort to improve the care experience. I know that without Epic my care would suffer so for the rest of this letter I will focus on my current and historical relationship with Epic. Currently, I am just a grateful user. In the past I was much more involved in strategies to use Epic to improve the care we provided to our patients.
I have a soft spot in my heart for Epic. Harvard Community Health Plan was the first Epic user in the Northeast. The “rollout” began in 1994, and I began to use Epic in 1995. These days, Epic is the most popular EMR in America and the world. Estimates of its market share range from 28% to 37%. The story behind Epic’s remarkable success is the story of its founder/CEO Judy Faulkner, now a very delightful multi-billionaire, who began the project when she was a grad student in mathematics at the University of Wisconsin. Many now consider her the most influential woman in healthcare.
One of my most pleasant experiences as CEO of Atrius and Harvard Vanguard was that Judy would call me for a long “catch-up” phone call about every six weeks. During my tenure as CEO Judy invited me to Verona, Wisconsin to address other CEOs at the annual EPIC users conference. She actually sent a private jet to carry me from O’Hare Airport in Chicago to Madison, Wisconsin. Epic’s magnificent campus is located just outside of Madison in bucolic Verona, Wisconsin.
Our calls began when our IT department discovered that after years of failing to keep up with Epic updates during the lean times following the collapse of Harvard Pilgrim, we needed to “reinstall” Epic. The “reinstall” was a big project. Our calls began with updates about the installation, but our conversations quickly moved on to discussions of literature, current events, and healthcare policy. Judy is a fascinating conversationalist who has a wide fund of knowledge and a delightful sense of humor. A good example of her strategy and her sense of humor was that when I visited the Verona Campus I discovered that in the men’s rooms over the urinals, she had signs that listed the ten reasons Epic would never be publicly traded. I digress, but when I think about the challenges that face both healthcare providers and patients I think that one of the most hopeful prospects for the future is the continued development of Epic and the innovation possibilities it offers to patients and providers.
I know that the EMR is a source of frustration for many healthcare professionals. It is also a fundamental requirement for today’s fee-for-service system of finance. The data that can now be extracted and analyzed is fundamental to managing in an environment of value-based reimbursement, quality improvement, and population management. I also hope that it will be the foundation for the effective implementation of AI as a strategy to improve patient access, reduce the stress on healthcare providers, and if wisely used, reduce the cost of care while it improves access and safety.
I don’t have experience with other EMRs other than a review of Allscripts while we were deciding whether or not to reinstall Epic, but now Epic, as used by Atrius and Dartmouth, definitely makes care more patient-centered for me and maybe the greatest benefit to attempts to improve the care experience for all patients.
I hope to continue to frequently report as a consumer of healthcare as we move toward the November elections. I know that the patient experience in the future, as well as progress in improving the social determinants of health, will depend on the “political determinants of health.”
Red Skies, Learning How to Read the Signs
The picture in the header for today’s letter was taken last Sunday at 4:59 AM by my wife. She captured the light just before the sun came over the horizon. She frequently rises early. As an old guy enjoying retirement, I consider early to be any time before 9 AM. What is obviously remarkable about this picture of the sky just before the sun rises in the East is that there is a very red sky. I know that some of my “Interested Readers” also follow my wife on Facebook and you may have already seen the picture.
I have many “holes” in my fund of knowledge which makes me a “lifelong learner.” I must admit that in almost 79 years I had not heard the aphorism until my wife quoted it that says “red sky in the morning, sailors take warning; red sky at night, sailors’ delight.”
There is validity to the red sky observations. Red skies at sunrise and sunset have solid predictive utility as noted in the previous link. The link even identifies that the wisdom of “red skies” is both Biblical and Shakespearian. Red skies are mentioned in a quote from Jesus in Matthew 16:2-3 and in Shakespeare’s Venus and Adonis. As a prediction, the red sky at sunrise from last Sunday morning was absolutely on the mark. By 6 AM we were in a downpour that lasted most of the day. My reference states:
A red sunrise can mean that a high pressure system (good weather) has already passed, thus indicating that a storm system (low pressure) may be moving to the east. A morning sky that is a deep, fiery red can indicate that there is high water content in the atmosphere. So, rain could be on its way.
Sunday was a washout. We have had some better weather, even intermittently gorgeous weather, since Sunday. Most of our temps have been in the low to mid-sixties with an occasional bump into the seventies. Clouds and rain have split the time evenly with more beautiful skies. Some of the days have felt even colder than sixty when we have had a heavy cloud cover.
The sum total of my weather report is that it could have been worse. I had hoped that I could discard my wet suit by now on my daily swim and maybe it won’t be long until I can because temps in the eighties and perhaps as high as ninety are in the predictions I hear for the weekend and next week.
If you think I am overly focused on the weather, you are right. The weather has been a lifelong obsession for me. The two apps I use most on my iWatch are the weather app and the exercise app. My focus on the weather has increased as the weather has become warmer and more violent as a manifestation of global warming.
One of my sons and his family live in California where over the last two years forest fires have come within a mile of their home, and where they have been isolated by roads that are washed out from the effects of “atmospheric” rivers” when they are not being baked by a “heat dome.” Another son and his family live in Miami where they have the threat of more and more frequent hurricanes, and have been deluged by almost two feet of rain this week. Their governor, Ron DeSantis, is focused on freeing Florida’s schools from the deleterious influence of progressive thought. Drag Queens reading to children seems to him to be a greater threat to his constituents than the increasingly violent weather. He has recently signed legislation to prevent laws from addressing global warming.
Sometimes I don’t know what worries me more, the weather or all of the other issues that divide Washington, our nation, and the world. Some issues are very complex. but it seems to me that there should be consensus on the weather just from our shared personal experience across the political divide. I do believe that all of our weather problems are connected and the solutions will continue to elude us until we can find some safe ground where productive conversations about global warming driven by our carbon fuel use can occur.
It was a dark day in our collective past when evangelical ministers announced that the AIDS epidemic was God’s response to homosexuality. I am not going to say that all of this violent weather we have experienced is God’s response to the attitude on the political right that the weather is not attributable to our overuse of carbon-based fuels. I think science offers a better explanation for what we are experiencing than efforts to explain it as the wrath of God, but I do wish that some influential Biblical scholar would advance the idea that when the scriptures say in Genesis 1: 26-28 that God gave man “dominion over the earth” the responsibility included the concept that we needed to be diligent caretakers of our environment which means putting the environment before corporate profits and personal convenience. I must admit that my own “carbon footprint” is part of the problem. If we are going to make progress we need to accept fixing the environment as a collective effort that knows no political preference.
I hope that your evening skies are red this weekend.
Be well,
Gene
