Hippocrates and the Internet

The Hofstra Northwell School of Medicine recently graduated its second class. The commencement was a wonderful “feel-good” event, complete with beautiful weather, happy graduates and proud families. The ceremony closed with the newly minted physicians rising to their feet and reciting the oath of the physician. In a nice touch, the other physicians in the audience were invited to renew their commitment to the profession by joining in. I found the whole thing joyous, and the opportunity to publically take the oath again was a moving reminder of what doctoring is all about.

Coincidentally, I also had the opportunity this week to lead one of the sessions in Northwell’s Physician Leadership Development Program,  part of a half-day session with Sven Gierlinger, our organization’s Chief Experience Officer, and Jill Kalman, the Medical Director of Lenox Hill Hospital, devoted to the voice of the patient.  My bit was about our “transparency project”to publish our physicians’ patient experience scores on our public website.  I used the story of how and why we did that as a case study that tied together the themes of physicians driving change and of improving the care we provide to patients and their families.

It was only after the fact that it occurred to me that there was a profound connection between the two events.

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Sound Familiar?

I am reading a really interesting book entitled Team of Teams written by (naturally) a team, which includes retired United States Army General Stanley McChrystal. McChrystal, you may recall, was the commander of US and coalition forces in Afghanistan before he got sacked for comments he and his staff made to a reporter for Rolling Stone. Prior to taking command, he served as the head of US Special Forces in Iraq during the Sunni insurgency, and this book is about how he and his deputies restructured that “Task Force” to meet the unprecedented challenge they faced.

Early in the book, he discusses the rise of “efficiency” as an organizing principle for industry and, by extension, other forms of human endeavor. He tells the story of Frederick W. Taylor who, late in the 19th century, introduced the idea of organizing activities in a factory so that the workers could produce “more, faster, with less.” Taylor also popularized the means of doing so by standardizing processes to reduce wasted time and effort and by optimizing each element of production. He was, one could say, the Lean production maven of his day. Here’s the passage from McChrystal’s book that really caught my attention, describing Taylor’s experience in a factory in 1874:

Taylor became fascinated by the contrast between the scientific precision of the machines in the shop and the remarkably unscientific processes that connected the humans to those beautiful contraptions. Although the industrial revolution has ushered in a new era of technology, the management structures that held everything in place had not changed since the days of artisans, small shops, and guilds: knowledge was largely rule of thumb, acquired through tips and tricks that would trickle down to aspiring craftsmen over the course of a long apprenticeship.

That transformation from artisanal workshop to organized enterprise, and from “tips and tricks” learned through apprenticeship to standardized work that can be specified and taught, sounds to me exactly like what medicine is going through today.  In fact, the changes in medical practice that have been advocated as the pathway to better, less expensive care have been described using the very same language.

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Population (Heart) Health

I had a great time at the national meeting of the American College of Cardiology (ACC) this past weekend.  I hadn’t been to “the meetings” in a few years, in part because my professional focus is no longer primarily clinical and well, I never really liked going even when it was. I generally believed (and still do) that I get more valuable information about new developments in cardiology by reading journals than by shlepping around some gargantuan convention center and listening to a few talks while dodging the barrage of drug and device manufacturers. Now that the results of “late breaking” clinical trials are instantly available (complete with slides and expert analysis) within hours of their presentation, I find the whole convention thing even less compelling.

So (with a nod toward the upcoming Passover holiday) why was this meeting different from all other meetings?

First, I had the pleasure of hearing my brother, David Nash, founding Dean of the Jefferson College of Population Health, deliver the Simon Dack lecture. As I said to him when he first told me he was invited (and wanted to know if it was a big deal), this is a big deal. It is the opening keynote for the conference, and is intended to set a tone or theme for the meeting, which draws almost 20,000 people from around the world. Here is a picture of him being introduced by the President of the ACC:

Nash_ACC

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Capitation? What Capitation?

Policy makers who are responsible for shaping how the federal government (the country’s biggest payer of health care services) pays physicians are pushing CMS on a rapid path away from traditional fee-for-service (FFS). As I discussed last year, CMS intends to have 50% of its payments flow through “alternative payment models” such as ACO’s and bundled payments by 2018, with nearly all of the rest of the FFS payments linked to quality measures.

While I believe this is generally a good thing, I pointed out recently that changing how the dollars flow is not the same as changing how the care gets delivered. Changing payment models facilitates redesigning care, but it doesn’t automatically create new care models. That only happens when physicians, liberated from the constraints of FFS, lead the way to do the right things for patient.

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Transparency 2.0

I had the opportunity recently to speak about our practice of posting patient comments and survey scores on our physicians’ web pages. The conference at which I presented was devoted to “transparency and innovation” and it became clear to me that making patient satisfaction scores public, while innovative today, will be universal pretty soon. The same forces that convinced us to go this far – rising consumerism among care-seekers, the ubiquity of ratings and information for other goods and services, and the evolution of payment models away from fee-for-service – will compel us to provide more and more information to patients and potential patients.

What might that look like? Here are a few possibilities.

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Incentives and Capabilities

The idea that we have to “change incentives” for physicians is all the rage. Oceans of ink are being spilled over the transition away from the traditional fee for service payment model to a menagerie of value-based ones. At the core of much of the discussion about how to make the transition is figuring out how risk-bearing organizations like large physician groups, health systems, ACOs and the like are going to provide appropriate incentives to the individual, front-line physicians who are providing the clinical care. It is not a trivial problem to solve.

The usual explanation of the challenge goes something like this: In the old days, when organizational success was defined by the number of “heads in beds” in hospitals or patient encounters in the clinic, it was pretty straightforward to “share” that success with physicians. The more patients they saw (or procedures they did) the better it was for everyone, and rewarding “productivity” floated everybody’s boats. Under alternative payment models, the measures of success of the organization are different and more complex – generally combinations of quality measures, patient satisfaction, efficiency, etc. – and translating that into new physician payment models is not so easy. If you continue to reward productivity, then it may defeat organization efforts at efficiency; make the payment model too complex by including many different performance metrics, and physicians don’t get invested in any of them; make the model too simple, and physicians will be insulated from the organizational goals.

Lost in all of the details of how to create the illusory “perfect” physician incentive program is the fact that incentives are only a part of picture. Combinations of carrots and sticks only work where the capability to respond exists. It is not helpful – to patients, doctors, or anybody else – to implement incentive programs that reward or punish physicians when the systems of care in which they work have not been redesigned to achieve the new goals. For example, tying a physician’s compensation to cancer screening rates in a primary care setting without designing a system to identify appropriate candidates for screening and facilitating the testing is just a demoralizing punishment for the physician.

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Test Responsibly

I got a heads up the other day that our organization had been dissed by a CNN reporter who was frustrated by her inability to get tested for Zika. You can read her original piece and the follow-up here. Short version is that she was upset that it was difficult for her to get tested after returning from a vacation to Costa Rica where she encountered “a good amount of mosquitoes” and later developed a mild febrile illness.

I won’t defend that she was made to feel like she was getting the run around, and it seems like – at the very least – we could have done a better job of communicating with her. But what she seems to dismiss, even though it goes to the core of her encounters with all of the medical providers she contacted, is whether she should have been tested at all. Continue reading Test Responsibly

More Public Reporting

Readers of this blog know that I am a fan of public reporting of performance data. I believe that data transparency helps fulfill an obligation to our patients to be honest about the care we provide, and is also a potent stimulus for improvement. There are obvious conditions that ought to be met before any sort of data – about quality, patient experience, finances or anything else – is shared in this way. The data should be meaningful (pertaining to something that patients are likely to care about), valid (the data actually measure what we say it measures), reliable (vary consistently with performance) and presented in a way that patients can easily make sense of it.

Our own efforts to report the patient satisfaction scores of Northwell Health Physician Partners physicians has been well received by our members and the press because it meets all of these criteria.

Some of the other public reporting efforts, such as recent reporting of surgical complications by Pro Publica, have been criticized for failing to meet the standards of validity and reliability, although I and others have been supportive of their efforts.

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Great Idea

Occasionally I come across something that is so profound that it illuminates how I think about a whole host of other things. The emerging science around the gut microbiome is an example. It seems like everywhere I turn there is more evidence that the variety and interactions of the bacteria in our intestines can affect everything from our mood to our risk of heart disease. It has re-ordered my thinking about health and wellness.

More recently, I read a book that has re-ordered my thinking about a lot of things, including health and wellness. The book is Connected by Nicholas Christakis and James Fowler. The central observation of the book is that we exist as social beings. We are all part of different networks of connected people, and the nature of those networks, and the people connected to us through them, have profound effects on each of us. You may have heard about some of the work that is summarized in the book, like the finding that if friends of our friends gain weight, we are more likely to do so as well, even if we don’t know those friends of friends, but that doesn’t begin to tell the story. Read the book. Or at least watch the TED talk which, when I checked, had been viewed over 1.1 million times.

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Happy New Year

I have never been a big fan of New Years Eve celebrations. Somehow the transition from December 31st of one year to January 1st of another always struck me as a poor justification for a party, and I had a hard time understanding the hoopla. As I have gotten older, however, I have come to appreciate the value of New Years as a pivot point – a chance to look back and assess the year coming to a close, and to look ahead to the one about to start. For the last couple of years I have cataloged the accomplishments of our medical group over the year ending and set out goals for the one starting, some of which I want to share.

A couple of accomplishments stand out as important markers of our continued evolution into an integrated, multi-specialty, physician-led organization. One was very “public” and easy to see and understand, and the other was internal and somewhat arcane but no less significant.

The public one was the publication of our physicians’ patient satisfaction data on our website. While the groundwork for this had been in the works as far back as the beginning of 2014, we “went live” with the program in August of 2015. Taking this step sent a powerful message that our medical group was committed to transparency of performance data and accountable for the experience of patients and their families. I believe it was also an important cultural milestone, demonstrating to our non-physician colleagues in the organization that we could – and did – take responsibility for our practice. The secondary benefits were also huge. We got lots of positive press, and our physician web-profiles now have a much higher visibility on search engines, edging out commercial rating sites such as Yelp and Healthgrades.

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