Starting With Curious

Our personal and professional lives are full of things we need to do just to get by, such as doing laundry or completing activity reports.  And then there are the things that are really critical to our success and well-being – building a relationship with a spouse/partner, mastering a professional skill.  While we often spend most of our time on those routine things, there’s a much bigger payoff from focusing on the important stuff.  In our culture enhancement work, we talk about these as our “Blue Chip”.  Granted, we do need to pick up a certain number of lower value white chips, but we need to make sure that with limited time and energy, we pay sufficient attention to the high value blue chips.

The CHW executive team recently spent part of a day sharing our blue chips for 2013.  I used two criteria to define a blue chip.  First, it’s something that is critical to the organization; by providing the foundation for future success, it’s a form of investment of time and effort.  Second, it’s something that requires some type of attention or intervention from me.  We all need to learn how to say no, but the blue chips are those things that we cannot say no to.

I have three blue chips for this year:

                1)  CSG Structure.  As we have discussed at the CSG Board and in various other meetings (and which I will discuss more about in coming posts), the healthcare environment is changing in ways that make it difficult for us to participate effectively given our current structure.  To be able to provide care while taking financial risk, we will need to have better financial integration, data sharing, and alignment of incentives with the hospital.  At the same time, we need to continue doing what we do best – providing outstanding patient care, innovative research, and training the next generation of providers.  It is absolutely essential that we figure out, very soon, how to structure ourselves to best meet these business, clinical, and academic needs if we hope to thrive in the evolving healthcare world.

                2)  Growth.  Our business has been relatively flat for several years, as a result of many factors, but with some areas of growth.  Why grow?  First, with increased competition from both pediatric and other health systems, non-growth is really decline.  Second, the emerging models of healthcare delivery and payment depend not only on better integration (see above), but bigger scale.  If we are to continue to grow, we need to focus on those areas of opportunity – our service lines and regional operations – more aggressively.

                3)  Ambulatory optimization.  Our outpatient clinics are one of the areas that has been growing.  We know our quality is great, but we’re increasingly being questioned about value.  To improve and demonstrate our value, we will need to capitalize on our investment in Epic, honing in on making our ambulatory operation more efficient.

Each of these is critical to positioning us for future success.  Yet all are large, complex tactics requiring attention and sponsorship at the highest levels.  Hence, my blue chips.

What are your blue chips for this year?

We all know the healthcare environment is changing: pressure on reimbursements from both public and commercial payers, need to control runaway costs, emphasis on payment for value vs. volume, etc.  I saw a video recently that steps back and discusses how the changes we are seeing in healthcare are tied in with much broader changes in society – what they refer to as “megatrends.” (I have to admit that the video, from Deloitte Consulting, is way too consultant-y for my taste, but it’s fairly short and raises many interesting points.)

Of the seven megatrends mentioned, five seem especially relevant to the pediatric world.  The most obvious is constrained resources.  In all segments of the economy, people are looking to do the same or more with less.  Quite simply, the money isn’t there.  Another is “big data.”  We are living in the information age, and while not all of that information is terribly useful, we are awash in it.  One the one hand, this gives us tremendous opportunities to learn, and to make data-driven decisions about care and our business; on the other, it means many others also have access to information, including patients, payers, competitors, etc.  Medicine has often had an asymmetric relationship between providers and consumers with regard to information, but the playing field is being leveled.

A third trend is unparalleled connectivity, with which we are all familiar.  Again, this is a two-edged sword.  We have tremendous possibilities for innovative ways of communicating with patients and families.  However, this connectivity has led to an increased expectation of consumer control in all walks of life.  People expect to have the information they want and need when they want it.  It’s another shift in the dynamic of the provider-patient relationship.

Consumer discontent is another general megatrend, manifest in the demand for demonstration of value.  Whether we like it or not, people are increasingly viewing health care as a service not as dissimilar to other services as we have traditionally treated it.  While I believe there will always be an important difference between medicine and say, dining out or financial planning, consumerism in healthcare is an inevitable consequence of consumerism in society as a whole.

The final megatrend is accelerated consolidation.  While politicians love to give paeans to small business as the  engine of growth, the fact is that consolidation is increasing in all sectors.  This is not necessarily a bad thing; there are many gains in both efficiency and quality that come from increased scale.  For example, numerous studies have demonstrated the association between volume and quality in medical procedures.  But how will we operate in an environment where bigger is better?

One of the take home points for me about all this is that, to the extent that what we see in the healthcare environment is a reflection of deeper, broader changes in the wider world, it’s harder to think that we can simply “weather the storm” and wait for these new fads to pass.  Bob Dylan was right, “the times, they are a-changin’.”

While the term evidence-based medicine (EBM) first appeared around 1990, its origins were in the 1960’s.  As recounted by Ariel Zimmerman, in her recent article “Evidence-Based Medicine: A Short History of a Modern Medical Movement,” one of the important driving forces behind the development of what became known as EBM was the institution of the Canadian national health plan (Medicare).  McMaster University, founded in 1968 in Hamilton, Ontario, is arguably the birthplace of EBM.  It was one of four new schools established in the wake of Canadian health reform, in an effort to integrate concepts of epidemiology and public health into the medical curriculum.  It’s not too much of a stretch to assert that a desire to ensure optimal use of finite health care resources – the best outcomes at the lowest cost – led to what eventually became a world-wide effort to promote a more systematic, less variable and idiosyncratic, approach to clinical care.  In other words, if you want value, practice evidence-based medicine.

This was a key revelation to me as I read the series of articles on EBM in the most recent issue of Virtual Mentor, the AMA’s on-line ethics journal.  We talk about value as the ratio of quality to cost; as a result, we often focus on the numerator and the denominator separately, with a natural inclination among clinicians to place far more value on the quality component than the cost.  But the best evidence-based practice automatically maximizes value, for at least a few reasons.

1. EBM leads to less variability; specifically, it eliminates variability that does not add value, while preserving acceptable variability due to either lack of evidence or evidence that multiple approaches might lead to the same value.  Such consistency will necessarily decrease waste.
2. The best evidence (which admittedly is not always available, especially in pediatrics) incorporates some type of cost-benefit analysis.  Synthesizing such evidence into care guidelines helps ensure that both the numerator and denominator of the value equation are considered.
3. One less-emphasized aspect of EBM is the explicit incorporation of patient preferences into the decision making process.  This can be done either in the guideline development stage, by using data about average patients into the analysis, or at the bedside with the use of decision aids.  This is really the ultimate way of ensuring that what we do is of most value to those we serve.

None of this is easy.  First, the evidence base may be lacking or uncertain.  Several of the articles talk about the challenges in communicating issues of risk and benefit, including a delightful essay by the late Stephen Jay Gould.  Another article talks about medico-legal aspects of EBM.  And there are indications that patients are somewhat skeptical about the whole notion of evidence-based medicine, feeling that all medicine must be evidence-based, and that more care always mean better care.  (Both of these assertions, by the way, are demonstrably not true.)

Nevertheless, as we work to improve the value of the care we provide – by decreasing our unnecessary variability – we’ll be best served by following the methods of evidence-based practice.  As difficult as it may be, it’s much better than the alternatives.