complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, musings, policy, politics, rapid learning health systems

A chat with Terry

An excerpt of a conversation with Terry Hannan on the business and bureaucracy of health and clinical care…

 

Terry, thank you for sharing those terrific papers by John Wennberg and Brent James… inspiring and affirming thinking.

 

Regarding your request for me to expand on how “true” priorities of the system are expressed:

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.[I would like you to expand this # as I am not sure I entirely grasp your focus here.]

 

Different stakeholders expect different returns from their investments. Roughly speaking (and apologies in advance for some of the generalisations that follow):

– politicians want to maximise votes in return for policy announcements

– bureaucrats want to maximise budget, status and power, and minimise risk in return to turning up to work

– public sector doctors want to maximise the health of their patients and status in return for turning up to work and working hard

– private sector doctors want to maximise income and status and minimise legal exposures in return for doing as much work as possible

– private hospitals want to maximise revenue in return for getting as many patients through their doors as possible

– nurses unions want to maximise members in return for negotiating improved work conditions

– not-for-profit (mutual) private health insurers want to maximise their perks by keeping doctors and private hospitals happy

– for-profit private health insurers want to maximise their profit margins by minimising doctor and hospital payments and maximising membership

– health researchers want to maximise their research capacity in return for increased publications

 

(Patients don’t even make my list of stakeholders, because they are not truly involved at present. An interesting remedy for this is citizen juries, a discussion for another time – did you ever engage with Prof Gavin Mooney before his untimely death?)

 

This suggests that each of these tribes wants a different “currency” in exchange for the “value” they deliver to the health system. They all use “patient interest” as the public justification for their claims on the system, but most of them are not actually remunerated in a currency that relates to the patient’s interest.

 

Indeed, in true “rent seeking” fashion, most of these stakeholders would rather not have to justify their remuneration to anyone – see this recent HLM news article.

 

At present, the easiest way to see what the system actually values is by looking at what it invests in. One “tell” that belies the health system’s “true” priorities is what it goes to the effort to properly records in electronic form i.e. billing data. This therefore suggests that money is the priority, and so it is what is tracked carefully.

 

If “patient interest” was truly the priority of the system, then far more effort and expense would be put into tracking patient outcomes, and in time, paying for them. On this, I am encouraged by the early shoots starting to sprout in the US around the development of ACOs, though I’m sure there are a lot more warts on it when seen up close.

 

My favourite “tale” of how to get there relates to how I’m told traditional chinese medical practitioners used to be paid. Everyone in the village would pay the practitioner as long as they were well, but stopped paying them whenever they ever got sick. This tight pecuniary alignment between patient and practitioner interest excites me, and makes me think there is still hope for ACO-style reform here. Indeed, my current health policy horizon doesn’t even involve hospitals and doctors, but rather looks at prevention efforts as the focus, as separate system with separate funding and separate participants.

 

I suspect this is best discussed over a long lunch or dinner, which I look forward to when the opportunity next arises.

 

Best regards, Paul

 

 

 

 

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 9:07 PM
To: Paul Nicolarakis
Subject: RE: contact

 

See my inserted notes.

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Tuesday, 17 June 2014 5:45 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

 

Thanks for your forbearance Terry.

 

I’m inspired by your resilience and enthusiasm for the area, and quite certain that this particular eHealth conversation is going to yield some interesting insights. I present these ideas (which tend towards the political more than technical or clinical) to you in confidence, with a view to sharpening up the thinking. In light of my political experience, I would not want to offend any past masters as they were operating within some diabolical constraints.

 

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.

 

Applying this analysis, it makes sense that an EMR purpose built to support HIV treatment in Africa would work because the only people involved in its development are dedicated clinicians, developers and minimal funding from similarly aligned entities with the specific purpose of improving the quality of care.

 

It also makes sense that physician led, integrated health systems (e.g. Regenstrief, Intermountain) that understand the “triple aim” nexus between high quality care and reduced costs would employ these systems successfully.

 

But finally, it also follows that systems built for governments in modern western democratic economies will never work because they are being built to get their political leaders re-elected, and make their vendors lots of money, but not really serve the community. The failure of these systems is ultimately guaranteed when the transparency they risk introducing into a system starts to threaten vested interests such as private medical providers and their associated institutions.

 

As per your slide from Blum, the red tail wags the yellow and blue dog because this is actually what matters in modern health care.

 

Microsoft learned this the hard way with their health solutions group efforts that I was involved in for a few years. The analytics software (Amalga) was quite impressive, initially developed by a group of keen, inquisitive (“data curious”) emergency physicians. They used the solution to monitor all sorts of clinical quality metrics across the business Washington Hospital Center service. Microsoft executives saw it, were impressed and acquired it. They then tried for 4 years to sell it to the world, only to discover that the “world” was not as interested in “clinical quality” as they were in bottom line revenues. What emerged from this experiment was the realisation that Microsoft had found itself ambushed by the gross conceit of modern healthcare i.e. stating that it was all about patient care, when in actual fact it was all about cash. Hence the highly administrative focus of most EMRs?

 

What has been terrific is to see US policy makers respond to this realisation by establishing “business models” around meaningful use and clinical outcomes. This is what seriously excites me now, though I suspect Australia is a decade away from adopting anything like what’s going on in the US at the moment.

 

One of the mantras we have here at the CRC (born in part out of our academic finance roots) is: “Healthcare is not a system, it’s a series of highly dysfunctional markets”. Applying this prism to healthcare really does start to clarify things, especially on the private side. On the public side, the currencies are sometimes different, but no less predictable.

 

I’ll pause here for fear of triggering some sort of global terrorist alert and/or offending you? Needless to say, I look forward to seeing where this conversation goes!

 

Best regards, Paul

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 2:15 PM
To: Paul Nicolarakis
Subject: Re: contact

 

Take your time you just spark my enthusiasm. The fact that you are interested is such joy. Terry

Sent from my iPhone Terry Hannan
On 17 Jun 2014, at 1:40 pm, “Paul Nicolarakis” <pnicolarakis@cmcrc.com> wrote:

Please bear with me Terry… I’ve got lots on at work… will respond soon… Paul

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Monday, 16 June 2014 2:12 PM
To: Paul Nicolarakis
Subject: RE: contact

 

Paul, thank you for the taking the time to write to me and if you think about it this is the first time in our long association where we have done a bit of eHealth “together”.

Based on your enthusiasm in the text I will now send you some materials which should further extend our discussions.

 

Firstly I have attached nan short slide set that I had prepared for the Sydney meeting-just in case.

The next slide is explained in the text flowing it.

<image001.png>

 

This slide is taken from B. Blum’s Clinical Information Systems and you can see the small RED Administrativebox in the top left which is where most HIS funding and management comes from and they try to meet the needs of the most important cost generator Clinical Decision Making.

This is confirmed by the work in cost reduction in CDSS as shown in the slide set attached by Tierney in Regenstrief.

Also in the references below.

1.         Slack WV. Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care. 2nd ed. San Francisco: Jossey-Bass; 2001 2001.

2.         Tierney WM, Fitzgerald JF, Miller ME, James MK, McDonald CJ. Predicting inpatient costs with admitting clinical data. Med Care. 1995;33(1):1-14. Epub 1995/01/01.

3.         Tierney WM, Overhage JM, Takesue BY, Harris LE, Murray MD, Vargo DL, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2(5):316-22. Epub 1995/09/01.

 

In addition these results from institutions such as Regenstrief, Intermountain Health (HELP System), Brigham’ and Women’s Hospital and Beth Israel Deaconess Hospitals confirm these findings and show that the current funding models by governments are incorrect.

 

I am attaching two summary papers from the Kenyan project.

I hope I have not burdened you.

 

Terry

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor  School of Human Health Sciences, University of Tasmania Department of Medicine, Launceston General Hospital
Charles Street Launceston 7250

Moderator: http://www.ghdonline.org/

Ph. 61 3 6348 7578
Mob. 0417 144 881
Fax 61 3 6348 7577
Email terry.hannan@dhhs.tas.gov.au

Skype: thehannans

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Monday, 16 June 2014 1:33 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

Paper (PDF): Are docs the weakness in the ehealth building

Dear Terry,

Thank you for sharing the paper and referring me to ghdonline.org – I’ve just signed up.

The paper touches on many issues close to my heart, but two that I am particularly interested in is the exploration of “healthcare as business” vs “the business of clinical care”.

I won’t commit my dismal views to this email for fear of offending due to lack of context, but would welcome an opportunity to a vigorous discussion with you when we next have an opportunity? To the discourse I would like to add “healthcare as a bureaucracy” and “the bureaucracy of clinical care” as I believe this frame paired with “business” frame are particularly explanatory of most things that happen (or in the case of e-health, don’t happen) in the sector. Needless to say, the clinical and information systems you helped to establish in Africa represent something of an ideal in my mind for an end-goal of a “lite”, modern, effective health system following the “less is more” maxim.

Looking forward to continuing the conversation.

Best regards, Paul

I’ve now seen the Australian health system laid bare while working for the Minister, and many other health systems up close while working internationally at Microsoft. I’ve concluded that with rare exceptions, health care represents “just another unremarkable business” or “just another unremarkable

bureaucracy” depending on the type of funding system that is used.