Hi everybody.
I am going to talk about quality safety value with a special emphasis on information technology
and you'll see why I've come to believe in the last few years that the transformation
of our world from paper to digital is a very big deal and that ultimately it will determine
how we do in our efforts to improve quality, safety and values.
I'll go through some core material in about 15, 16, 17 minutes and then chat with Roy
for a little bit and then open it up to questions.
Let me start with a little bit about the process of writing a book these days because it is
like everything else changed to a digital world and I'll just tell you how much it's
changed.
In the old days I've written several books.
In the old days after your book came out and you walked into a Barnes & Noble– you remember
those?
They were these bookstores, you looked around for your book, it was hidden behind a bunch
of other books, you took it out and you moved it to the front.
I mean incredibly stupid thing to do but this was what– all you could do to try to get
people to read your book.
Now these days, your book comes out and it's on Amazon and so when your book launches on
Amazon you are the lowest ranking book on their sales rank and that is about number
9 million which is incredibly depressing.
The best selling book in the world is number one– and then you begin clawing your way
up.
Amazon changes its sales ranking for your book every hour.
Anyone want to take a guess how often you check your sales ranking on Amazon in the
first month?
Every hour.
This happened to me about a month after my book came out.
The book is called "The Digital Doctor" and so I put in the search term "digital
doctor"– the title or the keywords, and my book, I was pleased to see, was the leading
book in that– with that term.
The second book was "Doctor Romance: Medical Erotica", "The Billionaire Doctor's
Erotica and Romantic Hospital Short Story".
If you look carefully, you'll realize that its customer reviews were every bit as good
as mine.
Really depressingly, if you look carefully, you'll realize that this book is free.
That's the competition.
That's what happens when you put out a book these days.
Let me take you back to a world– not so long ago, 17 years ago and think with you
about where we were in this path we find ourselves on toward we are today, which is, I think,
the need to transform care to improve value.
The year was 2000.
Think about it– kinder, simpler, gentler time– think about how old your kids were
at the time or think about presidential transition.
This was Clinton handing off to Bush.
That's where we were in 2000 so not that long ago.
I think most of us thought that quality and safety of healthcare were pretty good.
Our mental model for improvement or for when things went wrong –why that happened, we
now know is mostly wrong.
Our mental model back then was if there was something that didn't go right or we didn't
practice evidence-based medicine, it was because the doctor screwed up.
We now understand that although we need good doctors and good nurses, a lot of it is determined
by the integrity of the system– how well the system works, how coordinated it is, how
information moves around.
There was absolutely no business case to improve quality and safety.
Best hospital, worst hospital got paid the same.
Best doctor, worst doctor got paid the same.
You didn't know who they were either– no way of telling who was good, who was not
good.
None of us really knew how to improve care or what best practices were and all the above
led to predictable results.
This is not an indictment of us as physicians.
We were working hard, we were well-trained, we were doing the best we could but the evidence
came out and the evidence was fairly persuasive that quality was not that good, safety was
not that good and costs of course were were quite high and going up.
Let me take you in a couple of minutes through a tour of the last 17 years to talk about
how our world has changed from that innocent time where there was really no pressure for
value to where we are today.
I will go very quickly but I want you to sort of absorb how much change there is from what
I described– what is the situation in 2000.
I think this whole movement starts in 2000 when a report from The Institute of Medicine
comes out called "To Air Is Human".
This is the one that says we're killing a jumbo jet a day worth of patients because
of medical mistakes.
This launch is the modern Patient Safety Movement.
A year later, the same organization, the IOM, puts out another report called "Crossing
the Quality Chasm".
It says not only is safety not very good but quality is not very good and we need to address
it.
I'd say a major theme of both of these reports with this notion of systems thinking that's
not really about bad doctors– most doctors are very good, trying very hard.
It's about systems that don't deliver high-quality safe care.
This is Beth McGlynn, a researcher now at Kaiser Permanente.
In 2003/4, she published an article in the New England Journal looking at areas of medicine
where we knew the right thing to– the right treatment for blood pressure, the right treatment
for cholesterol, the right drug for sepsis.
How often did we do that thing?
The answer was 54% of the time.
If you can't forget that number remember a coin flip.
We got it right about half of the time.
Those of you who are Six Sigma fans, that's about one sigma.
That's a level of reliability that would put every other business I can think of is
out of business.
Imagine for a moment FedEx getting their package to you correctly 54% of the time.
Anybody think they'd be in business by the end of next week?
No way.
That was the state of American medicine.
The Joint Commission in 2004, the major accreditor of American hospitals, completely transforms
its process because of pressure from the public legislators and others– what are you doing?
You're accrediting hospitals but it's not safe.
It's not high quality.
They start unannounced visits.
It used to be my hospital had two years notice of when an accreditation visit would occur.
Now, they'll show up in our lobby on Monday morning completely on announced.
In 2005, Medicare begins– launches Hospital Compare, a website where they're now showing
results of performance.
It began with a number of simple process measures– did you get the right antibiotic for pneumonia,
the right med for heart failure and now if you've looked at it in the last several
years it has expanded to outcomes, infection rates, patient satisfaction rates.
Now as you probably know, there's a parallel website call Doctor Compare that does the
same thing for physician quality.
Peter Pronovost– some of you may know Peter is an intensivist at Johns Hopkins, publishes
a study in 2007 looking at the use of checklists in intensive care units throughout the state
of Michigan– showing a massive decrease in the rate of central line infections saved
hundreds of lives, millions and millions of dollars.
A little embarrassing that this is the great triumph of the patient safety field that we
figured out the checklists work but I think that's actually accurate.
We begin getting measured on patient satisfaction, patient experience starting about 2007/8.
In about 2010, Medicare starts giving out money to hospitals and doctors if they implement
computer systems.
I'll get back to that in a second because I think that turns out to be a central moment
in our story and inflection point.
Medicare launches value-based purchasing in 2012 and of course you all know about MIPS
and MACRA and the movement toward more and more value-based purchasing coming down the
pike very, very quickly with Medicare's stated intentions to move most of physician
payment and most of hospital payment to be based on value rather than based on volume
over the next several years.
In many ways Humana is ahead of the game here being in the middle of that transformation.
I want to make a point that this has nothing to do with politics– forgetting about what
happened last week with the ACA and whether that comes back and who knows but the ACA
in the debate about the ACA mostly was about health insurance, mostly was about coverage.
There is very little debate across the right and the left spectrum of the United States
about the premise that American medicine does not deliver a product that is high-quality,
safe, satisfying and a low cost.
The reason I know that is I've shown you 18 years of history that started under Clinton,
continue under Bush, continued under Obama, continues now under Trump and there's really
no reason for me to believe as you look at the politics and what's going to happen in
healthcare– I think there's a lot of questions there.
To me, there's essentially no question that the pressure that we're feeling to deliver
value will be durable and will only grow over time.
These are the medical students at UCSF.
They are spectacular, they're smart, they're interesting, they're optimistic.
I was talking to them a few years ago and they seemed a little too happy.
I said, "I need to make this folks know how hard it is to be a doctor and how much
change they're seeing", and I said– I sort of took on this gravitas in my voice.
I said, "You people are entering a profession totally different than what I entered when
I finished med school 30 years ago because you will be under relentless unremitting pressure
in your career to figure out how to deliver the highest quality, safest, most satisfying
care at lowest possible cost."
One of the students raised his hand and he said, "What exactly were you trying to do?"
I said, "That's a really good question."
On days that I and you were getting annoyed by all of the measurement and all of the pressures
and the surveys and all of that.
I want you to think about that student's question and realize that what is odd is not
that we are being now pressured to deliver value, what is odd is that it's new.
What is odd is that is not all that– not always been the payment system.
It's coming.
We're not quite getting it right yet but it seems to me the right thing to do to be pressured
in some ways to deliver better, safer, more satisfying care at a lower cost.
Let me toggle for a few minutes to why I think information technology is so interesting and
so important and why this entire discussion– everything I've just said to you I could've
said four or five years ago but I think it's now very different and will be very, very
different over the next five to ten years because of information technology.
Let me tell you why.
This is the curve of electronic health records in American hospitals.
Remarkably, less than 10 years ago, fewer than one in ten hospitals had an electronic
health record.
The same percentage is true for doctor's offices and you see by two years ago, we were
up to 84%.
The 16 data just came out and we're about 95% now.
Doctor's office is not quite that steep– up to 75/80%.
How did that happen?
Basically because the Federal government put $30 billion into computerizing the health
system.
It was not part of Obamacare– people get that wrong all the time.
It was part of the stimulus package when the economy imploded in 2008– you remember $700
billion for shovel ready projects?
One of them, believe it or not, was $30 billion to computerize healthcare.
Pretty good investment actually, if you think about it.
For $30 billion, they computerized a $3 trillion industry.
Pretty well leveraged investment.
Didn't get it right exactly, it would've been nice if they made all the computers talk to
each other but given what they had to do– they had to get the money out the door pretty
quickly– not a not a bad investment.
What this slide is designed to show you and get you to think about is that it is I think
it's not hyperbolic to say that the American healthcare system, in just the last five years,
has gone from a system– it's a system that is fundamentally about information, about
how we use information, how we use data, how we use science and how we apply it to better
the health of people.
We have gone from an industry whose information backbone was the piece of paper, the three-ring
binder, the post-it note, and the fax machine to an industry whose information backbone
is the electronic health record.
That has just happened in the last five years.
I'm going to come back to that because part of the frustration we're feeling is because
this is still pretty new for us– not at all new for every other industry pretty much
you can think of– maybe other than education.
To me, when I think about transformation and Roy and his colleagues asked me to talk about
transformation.
These are the two transformative issues that I believe we have in American healthcare.
One of them is the pressure to deliver high-value care– care that's better, safer, more satisfying,
better access, less expensive.
The second is that we have finally become a digital business.
If you ask me today and my day job– I run a very large department of medicine about
a half billion business, about a thousand doctors.
If you ask me what I'm obsessed about is I drive to work in the morning– there is
no question, it's the value pressure.
How do we get that right– how do we give better care, safer care, less expensive care?
If you ask me eight to ten years from now, I will virtually guarantee to you that this
will have been the bigger deal– the health IT transformation.
Why do I say that?
Because I can't think of another business that went– If you think about when it went
fully digital and then went out 10-15 years later, I can't think of another business that
was not turned up side down by that.
If you don't think that's true ask your friend who used to work at Macy's or at Barnes & Noble
or used to drive a taxicab.
My wife writes for the New York Times so if you think that, "Oh, I'm in a place that's
really good.
We're safe."
The New York Times would've gone out of business a few years ago they had not completely rethought
a digital strategy.
In other words, every business that we can think of 10-15 years out of ubiquitous digitization
was utterly transformed and all of the incumbent winners from the beginning were no longer
the leaders 10-15 years later.
Now, will that be our path in healthcare?
Probably not.
It's harder than everything else.
Doctors, hospitals have more powerful lobbies than taxi drivers do.
There are regulatory reasons.
If we screw it up, somebody dies.
There's all sorts of reasons why this probably won't be quite as fast as other industries,
but there's no doubt in my mind that we will see a similar path over maybe 10 to 20 years
not 8 to 10.
We have gone from paper to digital.
What could go wrong?
Think about the digitization of the rest of your life.
You have your iPhone, you download an app and off you go.
You're making a restaurant reservation.
You're getting directions to wherever.
It seems so easy.
What could go wrong?
Well, I spent a year thinking about this in writing a book about it because I was amazed
by the number of the things that had gone wrong, unintended consequences.
Doctors and patients not looking each other in the eye– all sorts of things that you
see in your practice every day.
This was a moment where I kind of knew that we were off the rails.
This is an advertisement I found for an emergency medicine job in Arizona a couple of years
ago.
"Arizona General Hospital coming to the Grand Canyon State.
Located in a Phoenix suburb."
It's a boutique general hospital.
It sounds pretty nice.
Here is what they're advertising for a doc.
What are they looking for?
They have an ER, which is good.
If you're looking for an ER doc, you want an ER.
They have a radiology suite with the latest gizmos, two state of the art OR's, outpatient
surgery– it's a little tiny place– 16 inpatient rooms, but the only part of the
ad that was in bold, clearly they thought their main selling point was they have no
electronic medical record.
In modern American medicine, they say, "Come work here.
You can still use paper."
It's really an amazing indictment of how wrong we have gotten this.
Part of the reason physicians are so unhappy about their electronic health record and by
the way as you probably know, physician burn out rates have skyrocketed in the last several
years and when you ask docs, "What's wrong with your life?", EHR's come out either
number one or number two on the surveys.
I think that's partly because they are not built very well, they're pretty unfriendly,
they're pretty clunky, but I think there are actually some deeper reasons that I want to
share with you– see what you think about this.
If you think about a doctor and the status of doctors in the old days and the autonomy
of doctors in the old days and think about now in a digital world, digital does two things
that are very interesting and actually creates a lot of the squeeze on experts of any kind,
but here are the ones I think are [INAUDIBLE] and the doctors.
There are unique and powerful enabler of central or corporate control, meaning now somebody
can be the boss of you.
If somebody believes that you were not practicing evidence-based medicine and your writing on
paper they're going to do a chart review a month later and maybe if they can read your
writing, they're going to say, "What were you doing here?
You don't remember what you were doing here."
Now, Roy and his colleagues or another insurance company or Medicare or your hospital or your
practice, can look at your practice in real time, push guidelines to you, grey out certain
options– that's an inappropriate MRI scan.
You're trying to click it and you're clicking it really hard and it's not firing because
the system eventually will figure out a way of preventing you from doing that.
That's troubling for us because we really like our autonomy but that's an inevitable
battle.
That's an inevitable tension as the pressure on all of us and our systems grows to deliver
high-quality evidence-based care, the computer will no doubt be part of the enabler for someone
to ensure there we're delivering better care.
You can also think of reasons why that's problematic but it's going to happen and I think if we
get it right it's probably a good thing.
On the other hand, of course, computers are the best enabler we've ever seen of democratization
and questioning of your expertise.
Obviously, you know that as patients come in having read something on WebMD or diagnosed
their actinic keratosis of melanoma because they used some dermatology app or whatever
it is.
You have the poor physician sitting in the middle and being squeezed by both patients
now questioning their expertise and eventually doing things themselves and then central control
of their [INAUDIBLE]– a very difficult place to be and not that surprising that we're
a pretty angsty group at this point.
Let me end with a couple of points about where we are and why I'm actually optimistic that
we're going to get to a really good place.
I don't think we are now.
I think we're actually in a pretty dark place because we have computerized but we have not
gotten it right.
This is a concept coined by Eric Brynjolfsson who is an MIT engineer and professor.
If you look at the date on this, it's 1993 so he clearly was not talking about healthcare
IT because there was none.
He was talking about information-technology as it entered other fields– manufacturing,
finances, travel.
What they found in the field after field was technology came in– everybody was excited
about it, it's wonderful, look at these computers and two years would go by– four, five would
go by and they weren't seeing the benefits that had been promised– not the quality
benefits, not the productivity benefits that they had been promised.
A Nobel Prize winning economist said in 1986 if he went on the factory floor, for example,
"You can see the computer age everywhere except in the productivity statistics.
We're not seeing the games that we expected."
What happens to the productivity paradox is it eventually gets better.
The average time in every other industry is about a decade.
As I say, I think healthcare will take longer.
We are more complicated.
It's difficult, but I believe it will happen.
When you look at the literature and talk to experts like Brynjolfsson, which I did, and
ask them, what happened to finally yield the benefits that everybody hoped?
It turns out there were two keys.
I think of this like a safety deposit box.
The first is: the technology gets better and if any of you are using– it doesn't matter–
Epic, Cerner, Allscripts whatever it is that you're using and then take out your iPhone
and look at the state of the technology and the user friendliness in the rest of our lives
versus our medical lives, you see that it's– there's almost 10 or 15 years behind in
health care.
The technology will get better and there's no question about that.
We're already beginning to see that some of that will be the Epics and Cerners of the
world, getting better themselves.
Some of that will be new companies coming in, taking the data from your electronic health
record and doing magic with it and then feeding it back to you and that's beginning to happen.
I can tell you that living in Silicon Valley, every company and Silicon Valley wants to
do that.
That's Google, that's Facebook, that's Apple, that's Microsoft– they are all
in in healthcare.
Essentially, they don't want to build electronic health records, they want to take the data
now and do their magic with it and give it back to you or the patients to change practice.
That's important.
It turns out not to be the fundamental thing that solves the productivity paradox.
The fundamental thing is reimagining the work.
What I mean by that is when we digitize; we typically digitize our old way of doing things.
We're not creative or smart enough to do anything other than that.
That's an old problem in technology.
Henry Ford was reputed to have said, "If I asked people what they wanted, they would've
said faster horses."
They had no ability to imagine what their life with cars would be until there were cars
and then there were car.
You needed gas stations, rest stops, you build suburbs– that all happens after the technology
is in.
That's what has to happen in healthcare– people to look at the physician note and say,
"Why does it look like that?
It looks like a digital piece of paper under a tab."
Why does it look like that?
Because that's what it looked like in a chart.
They say, "Haven't you ever seen a Twitter feed or a Facebook wall or a Wikipedia collaborative
note with audio or with visual?"
You have to reimagine– what are we trying to do here and build it for a digital age.
We've not really begun to do that.
That is when we will see the massive gains.
Let me end with this.
This is a story I read a couple of years ago I kind of like.
This is the Choluteca River in Honduras.
It's a part of Honduras that has lots of hurricanes, terrible weather and about 20 years ago, the
river was getting frayed and they needed to build a new one.
Because of all the hurricanes, they said, "We've got to build really a terrific
bridge here."
They called the world's leading bridge design firm in Japan.
They said, "We need you to build this bridge."
The firm said, "OK.
We can do that."
They used their best people, best materials, best computer programs and they built the
Choluteca bridge.
Lo and behold as they worried about a few years after the bridge went up along came
hurricane Mitch– blew down thousands of houses, tens of millions of dollars of damage.
The Choluteca Bridge had barely a knick.
I could imagine the bridge engineers in Japan giving each other high fives about what a
great bridge they built.
There was only one little problem and that was that the river moved.
This is us.
We have built a really, really powerful strong bridge in American medicine over a river called,
"Volume"– visits, hospital beds being full.
That's not where the river is anymore.
The river is over there.
The river is, "Value".
The river is, just as that medical student said, "That's weird.
Hasn't that always been the case?"
Well, no, but it is now.
How do we deliver care that's better, safer, more satisfying, more accessible, at a lower
cost.
We have to build a bridge.
It's not going to be completely digital, but it has to be partly digital.
It has to be– how do we use the information that we're so– spending so much time putting
into the machines.
How do we use it to allow us, to facilitate us, our ability to deliver better, safer,
and less expensive care?
Let me stop there.
Thanks so much for your attention.
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