IBM’s Watson and the Triple AIM

I recently attended Simpler Consulting’s 11th Annual North America CEO Symposium. Like much of healthcare, Simpler has been a player in a serial process of mergers and acquisitions. Two years ago, Simpler and JWA, another Lean consultancy were acquired by Truven Health Analytics, not very long after Truven had spun off of Thomson Reuters. Within the last year IBM Watson Heath, a new company created by IBM over the last two years, acquired Truven, Simpler and JWA. We all learned a few years ago that Watson can win playing “Jeopardy” but can it be a trusted colleague on the road to the Triple Aim?

 

As is true when delivery systems consolidate, IBM Watson Health is working to link all of its newly acquired organizations into an integrated whole that will enable its customers to improve their performance. It is a huge undertaking. Over the last several months Truven, Simpler, JWA and all the “other recently acquired assets” have been working with IBM Watson’s management team as well as advisors from customers and others in the healthcare industry to create an innovative new organization through the orderly strategic assembly of these assets.

 

With “other recently acquired assets”, I was referring to the astonishing fact that during its brief existence IBM Watson Health has also acquired Phytel, Explorys, Merge Healthcare, and The Weather Company. They have spent over 4 billion dollars acquiring the component pieces of a company that will be foundational to healthcare transformation.  You ask, “What is the Weather Company doing in the mix?” Well when you are predicting the risk that the frail elderly or patients with lung disease might have, it is good to be able to factor in the weather.

 

The ultimate goal of this audacious exercise is aligned with the Triple Aim. The planners are confident that they can make a successful application of technology and improvement science grounded in data analytics and the evolution of cognitive analytics. They are comparing their project to the effort to put a man on the moon. IBM was a big player in that effort and sees no reason why being a facilitator of better health for everyone should not be their next big audacious objective. The big question in my mind was whether the individual clinician would ever work with Watson as a “colleague”, or would a patient ever feel that Watson had directly made them better and have the same sense of gratitude that they sometimes feel for an empathetic physician who had made a difference in their care.  

 

Everyone at the meeting seemed convinced that the greatest threat to the future health of the nation was our continuing inability to reduce the cost of care. Most of us believe that most important accomplishments since the beginning of the quality era in the late nineties will survive the uncertainties of the election. One speaker spent time emphasizing the huge bipartisan majorities that produced MACRA as evidence that the drive for value based objectives would survive.

 

Equally true was the wide acceptance of the analysis that quality is a function of our patient centeredness and our ability to deliver care that is safe, efficient, effective, timely, and equitable. It’s been fifteen years since publication of Crossing the Quality Chasm. That document is now foundational to a shared belief among the attendees that the improvement of our current processes of care is necessary, but just improving what we do will ultimately be insufficient to achieve the changes in performance that must occur for us to produce:

Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.

Achieving the lofty vision of the Triple Aim will demand improvement plus substantial innovation and require the spread of all that has been learned, but not adopted, by so many who continue to try to get through each new day with skills that have not evolved to match the demands of their customers/patients. The world has changed around healthcare as it persists with a “guild mentality”. How will Watson fit into the current struggle to lower the cost of care while continuing to improve quality?  

 

Our cost and quality challenges are complex and are both external and internal. Externally, consumers and purchasers of care are expecting more. At every level of financial involvement, from the individual patient to public payers and the large multinational employers like IBM, there are demands for increased value and lower expense. The cost of care is rising and patients are absorbing much of those increases in the form of higher costs for basic coverage that is even more expensive because of large deductibles and higher drug costs. Consumer and payer dissatisfaction and anger are accelerating the demand for healthcare to change.  

 

Internally, siloed organizations with unwarranted variation in practice, and wasteful operations are struggling to survive while fighting with employees and dissatisfied customers even as they experience even greater regulatory scrutiny. It is interesting to postulate how we got here, but it is more important to realize that just continuing to do what brought us to this moment with old tools and yesterday’s mindset will not work.  Can Watson be a game changer and fit into the search for solutions?

 

At one moment near the end of the conference one speaker stated that doctors over sixty would not be able to make the transition necessary to meet the cost challenges. He then went on to say that it was unlikely that those over fifty could be reoriented to new pathways of care. He was betting on the Gen Xers and the Millennials. I hope that he is wrong about those who are “in the way”. I do believe that one of the other speakers was right when he predicted that our energy for change will be generated by fear of financial failure. Perhaps Watson can help us rise to these internal and external challenges and provide us much needed help as we seek to deliver on the justified demands of consumers and payers.

 

There is much to do. As I have said before, “the What”, the Triple Aim, is now a settled question and an accepted concept.  “The Why” is also becoming increasingly clear. Our communities demand more and our current methods of care are unsustainable and frequently ineffective. “The How” is the challenging question that will require more than just the effective use of the assets we have. We must pursue the development of new and effective tools like Watson. may offer. We must spread the acceptance of improvement science and teach its culture and tools.  We must cultivate the engagement of individuals and communities in the recognition that we can never enjoy the health we desire without much work on the non medical or social determinants of health. Finally, there is the “Who”. One speaker referred to Hillary Clinton’s, It Takes A Village. I agree. I think “the Who” is everybody. Healthcare professionals of all stripes, medical organizations across the spectrum of sizes and missions, individuals, families, communities, employers, and public servants all must be joined like a village for concepts like population health, value creation and the creative use of big data and machine learning to be successful.

 

Bill Kassler, MD, MPH who is the Deputy Chief Health Officer and Lead Population Health Officer of IBM Watson Health was recruited by IBM because he has spent his career “at the intersection of clinical care and population health”. When he joined IBM he had been working as a PCP in an FQHC while serving as CMO for the New England Region of CMS. He has great expertise in the value based reimbursement efforts of CMMI. Dr. Kassler laid out the vision of IBM Watson Health and described the power of coupling machine learning and artificial intelligence with the efforts of process improvement. It was “blue sky”, “Buck Rogers” thinking. I was captivated by the possibilities of what might happen if we could incorporate the ability of Watson to augment the skills of clinicians in practice. What if a clinician who is uncertain about the next step in the care of a complicated patient could ask Watson how the patient compared to other patients and what had worked best for patients that were matched? Watson can search a data reservoir of hundreds of millions of cases. There are so many possibilities to explore and so much waste that could be reclaimed. My head is still spinning.

 

In the new world of possibilities that technologies like Watson offer, clinicians will need to be trained differently. Efforts at process improvement and a focus on population health will require skills that traditional medical education does not offer. Kaiser has decided to open a new medical school that will produce physicians who are trained for the challenges of the practice in 2030. Christine Cassel, MD, the former President and CEO of the National Quality Forum, the ABIM and the ABIM Foundation and an advisor to President Obama on his Council of Advisors on Science and Technology is the Planning Dean for the new medical school which will open in 2018. It was under Dr. Cassel’s leadership that the ABIM launched the Choosing Wisely Campaign. The doctors that Kaiser will produce will be comfortable with collaboration, understand how to bring the insights of population health to the individual patient and will be ready to use the power of technologies like Watson to achieve the Triple Aim.

 

The world where newly minted physicians and perhaps some of our more open minded clinicians who are currently in practice will work will not be the same world we live in now.  The opinion of Michael Nowicki, Professor of Health Care Administration at Texas State University is that insurance companies will go away over the next decade as employers and public payers negotiate directly with integrated delivery systems. The impact of medical costs on the growing national debt will finally force the relative reduction of resources for healthcare. Providers will be accepting more risk through mechanisms of capitation within ten years. If this is true most organizations are not ready for the challenge. Will Watson be available and useful in the turbulence of the transition?

 

Dr. David Nash is the Founding Dean of the Jefferson College of Population Health (the first in the country) at the Thomas Jefferson University in Philadelphia. He is convinced that our failure to understand and incorporate the principles of population health into our plans and workflows have lead us to waste trillions of dollars and underfund services and infrastructure that are desperately needed. 10-20% of “health” is attributable to healthcare care. 80% of health is a function of realities that do not occur in a hospital or a doctor’s office. Only 3% of Americans regularly do 5 things that optimize their possibilities for health. Is there a role for Watson as we try to help patients do the things that we know contribute to health?

 

1. Exercise for 20 minutes 3 times a week.
2. Don’t smoke.
3. Eat fruit and veggies regularly.
4. Wear seat belts regularly.
5. Are at an optimal BMI.

 

Connecting what we do to manage populations to improve the health of individuals will require tools like registries, new collaborations in the community to improve the social determinants of health and an understanding of vulnerabilities and priorities of populations that both big data and Lean can facilitate together. Combining process improvement with the power of Watson will be hard work. Work flows must be developed. There will be challenges that will surprise us. The status quo, no matter how dysfunctional it is and how poor its results, never goes away quietly. Change is an adaptive process but I have a renewed hope that good things will eventually happen and that we will figure out how to use tools like Watson to bring the benefits of the Triple Aim to patients and healthcare professionals sooner than many expect.