You Get What You Ask For

This post was originally featured on EMRandHIPAA.

I recently had a chance to meet Dr. Dave Levin, the first CMIO from Cleveland Clinic, at the Texas HIMSS conference, where I spoke about Google Glass in healthcare. During his keynote, he gave a quick overview of his book – mHealth: Global Opportunities and Challenges – that I’m reading now.

The most important thing I took away from his presentation is that people will do exactly what you tell them to do, not what you’d like them to do. More specifically, people will optimize against what they’re measured against. This is a classic business truism, but one worth repeating.

In order to receive Meaningful Use cash for adopting EMRs, providers are jumping through an excruciatingly difficult series of hoops. Among those hoops is the primary theme of MU Stage 2: patient engagement.

But patient engagement is not an end. Patient engagement is a means to an end. Although there are certainly disagreements on what the end should be (depending on one’s political alignment), the federal government is clearly pushing value-based care delivered through PCMH and ACO models.

So why are we measuring arbitrary metrics such as “5% of patients engaging with their providers” through some sort of patient engagement product? By incentivizing arbitrary usage metrics, we will see little healthcare delivery transformation, despite all the intent in the world. Instead of flipping the clinic by utilizing patient engagement tools as part of a broader healthcare delivery strategy, providers are just going to optimize to barely get by getting 5% of their patients to send them a message through their patient portal.

Consider instead these potential alternative metrics, that better reflect the spirit of the MU regulations:

1) Percentage of patient population cared for under a value-based rather than volume-based model.

2) Percentage of simple visits – script refills, ear infections, etc. – conducted remotely via telemedicine instead of in person.

3) Percentage of visits avoided simply by answering questions via asynchronous secure messaging/pictures.

4) Percentage of complex visits handled by an MD (in which the intention is to hand off simpler visits/procedures to non-physician practitioners to lower costs)

There are certainly problems with some of these proposed metrics. They don’t solve all incentive problems; the system can always be gamed. But compared with existing measures, the above metrics do much more to force providers to rethink care delivery models and flip the clinic.

Some people will interpret these metrics as a way for the federal government to institute socialist control over healthcare delivery. These fears, though, are disproportionate. While a slippery slope argument can be made in this case, the US government has only on a few occasions actually nationalized private functions. In most of those cases, the nationalization was short-lived (such as General Motors 2009).

Given the clout of the AMA and other players, the probability of sliding down this slope seems exceedingly low. History has shown that there is too much friction in the status quo in the US healthcare system for the system to change on its own. At any rate, some change is better than none!

So, Uncle Sam, hear this: you get what you measure. So please measure what you actually want.

The Nurse Will See You Now

This post was originally featured on EMRandHIPAA.

The Atlantic just wrote a piece highlighting the growing trend of non-physicians (commonly referred to as midlevels) providing healthcare. The reason is simple: supply and demand–more precisely, a fixed supply.

For any location where a patient demands healthcare services, there is only a binary result: either there is a qualified healthcare professional available to deliver care, or not. This slide (from Pristine’s investor presentation) illustrates this:

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The supply and demand problem is further compounded by an archaic regulatory system. The path toward becoming a physician, at least in the US, is so arduous that the decision to pursue becoming an MD must be made by age 18 or 19. Even if a huge cohort of 18 year olds suddenly decided they wanted to be physicians, the artificially capped supply of available residency slots each year stimies traditional supply and demand economics.

Nursing, on the other hand, has a more varied cohort in terms of age of entry. Many nurses don’t enter the profession until well into their late 20s or 30s. The same is true of physician assistants. This has resulted in a more liquid supply of non-physician practitioners, and these non-physician practitioners are available to respond to the influx of new patients resulting from the ACA, and to the growing number of retiring baby boomer population.

Given the fixed supply of physicians, there are two fundamental ways to solve the supply and demand problem: make physicians more efficient, or substitute physicians with others who can do an equally good job for a given patient’s needs.

The realities of practitioner supply suggest that nurses and other non-physician practitioners will deliver an increasingly large percentage of healthcare services. Physicians will be relegated to the “high end” per Clayton Christensen’s disruption theory. That could manifest itself in a future in which midlevels deliver primary care and triage more acute conditions to “higher end” specialist physicians.

The greatest challenge in the triage-centric model led by midlevels is the (historically quite poor) communication among healthcare providers. We will need a robust technological infrastructure to support the seamless transfer of patient data among providers. Additionally, we’ll need more capable communication tools to empower providers to connect with one another and with patients regardless of location.

Telemedicine seems to be taking hold to power a future in which location is irrelevant. Interoperability is improving within health enterprises, though there are some signs that community health information exchanges (HIEs) are notdoing as well as many had hoped.

At some point down the line, we’ll likely look back and wonder why location mattered so much. It shouldn’t, and because of telemedicine, and liquid data connectivity, it won’t.

Happy Mother's Day! Telemedicine Edition

This post was originally featured on EMRandHIPAA.

In honor of Mother’s Day, I thought I’d write a post highlighting how telemedicine can benefit mothers caring for their children.

Many children can get up to 6 ear infections per a year. Everytime it happens, children complain, and inevitably mothers take their kids to the pediatrician. In most cases, the mother already knows what the problem is (because it’s frequent and easy to diagnose), but yet she has to drag her child to the doctor, leave the kid in a room full of other sick children for half an hour, only to spend 5 minutes with the pediatrician to get a prescription for antibiotics. Then she has to drive with her child to the pharmacy to pickup the medications, and then get her child back home. Meanwhile, she’s falling behind on work.

What a pain. I can’t imagine fighting that battle even once per year, let alone 6 times!

Healthcare shouldn’t be hard. And in my cases, such as the pediatric ear infection, it’s not. What if mothers bought a Cellscope, took a picture of her child’s ear, sent it to her doctor, then received antibiotics from PillPack the next day? Or better yet, what if the medications arrived via drone delivery within an hour?

I’m optimistic that 10 Mother’s Days from now, moms across the country won’t have to deal with so much frustration to solve what is such a simple problem.

The Pristine Story: Springing Ahead

Since the last episode of the Pristine Story, we've been busy as springtime bees!

Since announcing our launch at Brown University, we've gone live at three additional hospitals, with several more coming in May. We're holding back on PR for a bit, but will have some big announcements in the coming weeks, so keep an eye out for those.

We're not just busy at home, though...

HIMSS INNOVATION SUMMIT

Dr. Paul Porter (from Brown University) and Kyle will be presenting at the National Healthcare Innovation Summit in Boston.

They'll discuss Brown's experience using Glass for telemedicine in the ER, and present data on how Pristine's solutions dramatically improve efficiency in the care delivery system.

ATA ANNUAL MEETING 2014


If you're headed to the American Telemedicine Association Annual Meeting in Baltimore, come visit us at Booth #1814. We'll be the ones in clever T-shirts and Google Glass.

In fact, we're giving away a Google Glass unit to one lucky ATA attendee, so make sure to stop by our booth and enter our raffle!

Engineering Update
 
Our engineers led the most recent meeting of the Austin Google Developer Group (GDG) diving into the innards of WebRTC on Android.

Keep an eye on The Looking Glass (our engineering blog) over the next few days for more on how Pristine uses WebRTC, our slides from the GDG meeting, and more.
 
Finally, while it may be busy in the land of Pristine, we still find time to commit our thoughts to prose. To wit, our recent blog post (penned by Kyle) that examines the difficulty in reducing the cost of care.

And if you need more material to for your week's reading. There's plenty more analysis, commentary, and forward-looking thought on our blog. Enjoy!

That's it for this installment of the Pristine Story, stay tuned for more!

Until next time,

Healthcare Entrepreneurship-as-a-Service

This post was originally featured on EMRandHIPAA.

We are witnessing a dramatic unbundling of the services that power business. Almost every aspect of business can be unbundled into a monthly service.

My startup, Pristine, runs on a number of unbundled cloud services that until recently, would have traditionally been outsourced to HR firms or mega-IT companies. We run Pristine on ZenPayrollRelateIQGoogle AppsExpensify,Maxwell HealthXeroResumatorMediaTemple and more. Similarly, we’ve built our flagship service, EyeSight, on top of a broad array of development tools and services (check out the Pristine Engineering Blog to learn more about how the sausage is made). We’ve made it a priority to invent and do as little as possible by utilizing 3rd party stacks and services everywhere possible.

Healthcare is not immune to this trend. There are a number of companies that are unbundling health IT entrepreneurship:

This list should be 10x longer than it is. With all of the capital and startups entering the health IT space, companies providing the infrastructure to accelerate growth will thrive. As the old saying goes, “During a gold rush, sell pickaxes.” The companies listed above are selling pickaxes to proverbial gold miners.

I’ll conclude this post with some areas that can be commoditized as a service. Feel free to leave comments on other areas or companies that I missed.

  • Interoperability as a service (in lieu of HL7)
  • HIPAA compliant videostreaming as a service
  • HIPAA compliant image / video sending as a service
  • Analytics as a service