Saturday, March 31, 2007

Pay-for- Frustration in Small Home Health Agency

Problem: Too Many CMS Rules and Paperwork to Ensure “Quality”

Solution: Have CMS Bureaucrats Serve Time in Home Health Agencies as Part of Job Training

After I wrote a Healthleaders article on Pay-For-Performance possibly not being what it’s cracked up to be (see yesterday’s blog), I received this note.

Dr. Reece:

I applaud your common sense description of the P4P plight we all face. I’m the director for a Home Health agency in Ohio. We face the same problems in the Home Health environment with respect to poor patient compliance based on cultural and financial problems that patient care is frought with.

You were right on with the comment, politically incorrect or not, that "Patients are equally responsible for bad disease outcomes". Is it fair to punish physicians and agencies for poor choices?

And what about the nature of the human condition itself that lends to the inevitable outcome of the body "wearing out"?

And what of the patients who are non-compliant and are given notice by their physicians that they will no longer treat them? We all know the P4P quality measures will be negatively affected by these types of patients.

The same holds true in home health. There is already fear that we will avoid co-morbid patients because of predisposed potential for a downhill spiral prior to discharge from home care.

Chronic conditions such as COPD, diabetes, CHF, diabetic wounds among others are repeat offenders when it comes to re-hospitalization and emergent care.

This can't be helped and so I ask those that will rely on P4P as a payment guide to ask this question: What will become of agencies who care for these patients regardless of P4P percentages?

And what will become patients who are avoided because P4P threatens to remove these monies if the percentages fall below "their" idea of quality?

Ask these patients who depend on home care nurses and aides who help them cope with their medical problems. Not to mention physicians who rely on us as well to manage follow-up and change in treatment regimens so as to prevent emergency room visits.

I recommend that those who make these determinations should walk a mile in ALL our shoes!

Ellen Henderson, RN, Director
Twin City Home Health
Dennison, OH 44621
740-922-7450 Ext. 3901

I followed up by calling Ms. Henderson. She runs a small home health agency – 12 employees with about 40 home health patients. The agency is affiliated with a 25 bed rural hospital.

She says current CMS reporting requirements burden her staff. Federal rules may require 2 to 4 hours of paperwork to meet quality requirements. “That’s time we could better spend caring for patients.” What P4P might add to the red tape, she doesn’t know, but she fears the worse.

Many of her patients are non-compliant. Their behavior poses safety hazards beyond the control of her staff. One client insists on keeping kerosene cans next to his oxygen tank; another suffers a wound infection from a dog licking his wound.

Even though satisfaction surveys show a 99% approval rating among her agency’s home health clients, she notes “We look bad on quality surveys because we accept patients with chronic disease and multiple co-morbidities.”

Other agencies hesitate to accept these patients because they reflect badly on quality ratings, She said home health agencies across the land are resisting mandatory P4P participation “because it would put us out of business.”

She said home health agencies would like to see major changes in regulations that would not punish agencies who care for chronically-ill patients with poor prognoses.

I have a modest proposal: have fledging CMS bureaucrats spend a week in a home health agency filling out CMS forms, going on home calls, and observing how patients comply as part of their job training.

The moral is: Bureaucratic regulations have unforeseen complications: things don’t always look the same from the bottom-up as from the top-down.

Friday, March 30, 2007

Doctor Patient Relationships - Pay for Whose Performance

Buzz, Metrics, Outcomes. and Human Nature

This originally appeared HealthLeaders News, Mar. 16, 2007

As an occasional contrarian, I sometimes question accepted wisdom. One piece of dogma I hear repeatedly is that physicians should be held directly responsible and strictly accountable for patient outcomes and should be paid accordingly. That’s the essence of arguments for pay-for-performance programs.

Below, I raise these three questions:

1. Should physicians be paid extra for performance by “administrative pricing regulators” when physicians are professionally obligated to do the right thing in the first place in the best interests of patients?
2. Will P4P in all its complexities and unforeseen consequences slow growth of healthcare spending?
3. Should P4P programs be extended beyond the hospital to outpatient settings?

Contagious Buzz

Accepted wisdom is contagious. Hang around hospital and health plan executives long enough, and you will hear a lot of buzz about quality.

The buzz goes like this:

• “Quality and metrics are where it’s at.”
• “All we need to do is to get our arms around the metrics.”
• “If only we could get clinicians to behave and follow measurable quality indicators.”
• “Pay for performance is the wave of the future, if only doctors would climb on the bandwagon.”
• “Manage doctors, and you manage quality.”

Metrics conflicts

The buzz on the doctor side of the aisle may differ. Some doctors are openly skeptical about the value of P4P. Why are some doctors dubious about measuring outcomes and being paid for them?

From the doctor standpoint, there may be several reasons, as evidenced by the Winter issue of the Minnesota Quality Review report, which contains a number of provocative articles.1

Here are some of their titles:

• “Paying for Performance: Physicians Support It But Want It Tweaked, Tested, and Watched Closely.”
• “Not Really What the Doctor Ordered.”
• “Is Everything Negotiable: Physicians Find They Often Have Some Leeway to Negotiate Pay-for- Performance Goals with Health Plans.”
• “Pay for Whose Performance? Minnesota Clinics Carve Up the Bonus Pie in Different Ways.”

I take these articles seriously. As former editor of Minnesota Medicine and a lifelong student of healthcare in Minnesota, I know Minnesota physicians, who tend to congregate into large well-managed groups, are scrupulously dedicated to quality.

Serious Questions

Yet Minnesota doctors question whether:

• Quality measurements are for the benefit of hospitals and health plans rather than for doctors and patients. In other words, pay for whose performance? P4P, I find, is not really what most doctors would order to judge their own performance.
• P4P bonuses for doctors, typically in the 3 percent range, are a sufficient incentive to pay for installing expensive electronic health systems to record doctor-entered quality indicators, which are necessary to track outcomes.
• They should have more leeway in negotiating P4P goals with health plans and in setting realistic standards.
• P4P programs are really effective in improving quality and may be at the tipping point.
• Current evidence of P4P justifies them being applied nationally.2,3
• Health plans and hospitals realize patients are often more responsible for disease outcomes than doctors themselves.

Thin Evidence of P4P Effectiveness

Why is the increase in quality and outcomes only marginally effective with P4P programs? After all, it is intuitively compelling that a broad base of evidence aligning outcomes with bonuses would work. However, the evidence is thin indeed that P4P actually works.4,5

What’s going on here? Is it because:

• Doctors aren’t concerned about quality?
• Demands in costs and efforts in money, training, staff time in installing systems and entering and tracking data are excessive?
• Doctors are technophobic?
• Sixty percent of doctors are in practices of four or less and simply lack the IT infrastructure to track P4P?
• Patients fail to change behavior and don’t comply with instructions once out of the reach of doctors and hospitals?

Doctors and Bad Outcomes

Politically and intuitively, it’s easy to blame doctors for bad outcomes. Doctors are the authority figures. Doctors write the prescriptions, treat the patients and control the money flow. You often hear the truism doctors generate or control 80 percent of money expended in the system, although I have yet to meet a doctor who believes this.

It would also seem to make intuitive sense that improving “processes of care” in the outpatient environment would improve outcomes. But this may not be so. The Health Disparities Collaboratives of the Health Resources and Services Administration recently performed a controlled preintervention and postintervention study of 9,658 patients with diabetes, asthma and hypertension participating in community health centers quality improvement program.6

The conclusions? “The Health Disparities Collaborative significantly improve the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.”

No mention was made of the patient behavioral factor, merely that “the substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods.”

In judging outcomes, it’s much harder to measure noncompliance and unhealthy behavior of patients outside traditional care settings. Besides, patients are supposedly at the mercy of the doctors and are most vulnerable to high health costs.
Can you imagine a health plan or Medicare official saying, “Patients are equally responsible for bad disease outcomes”?

I can’t. That would be politically incorrect, certainly insensitive and maybe even scandalous.

Human Nature and the Declaration of Independence

There are other factors as well–human nature and independent patients with their own minds. As John Naisbitt points out in Mind Set! (Collins, 2007), the U.S has an “overwhelming bottom-up society.” Americans believe in individualism and freedom, and patients tend to behave the way they want to behave and change behavior and old habits only reluctantly.

As an example, 40 percent of type 2 diabetics at risk ignore doctors’ advice to be active. And the more in danger patients are, the less likely they are to be inactive.7

A Smoking Gun

I vividly remember a photograph of John Johnson, a West Virginia coal miner, on the front page of the New York Times (Eckholm, Eric, “Medicaid Prods Patients Towards Health,” December 1, 2006).

Johnson, 61, had lost a leg to diabetes and was smoking a cigarette in the Times photo. When doctors urged him to change his diet and to stop smoking to qualify for better Medicaid benefits, Johnson said, “I told them I eat what I want to eat, and the hell with them. I’ve been smoking for 50 years–why should I stop now?”

Self-evident Truths

Other self-evident truths exist as well. Here are five:

1. People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work. The system recognizes this. It is decentralizing and moving chronic care management to homes and worksites. Internet and nurse monitoring may help close monitoring disease gaps. But gaps in care--gaps beyond the physician’s control--still loom large. Insurance coverage may or may not be important in outcomes. According to Amy Finkelstein of MIT, Medicare had no effect in reducing elderly mortality in its first 10 years of existence (“The Cost of Coverage: The Sobering Lessons of Medicare,” Wall Street Journal, February 28, 2007.)

2. Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise. The lack of prescription compliance has led to a boom in physician office dispensing, the rationale being that patients are more likely to follow instructions when the doctor directly hands them the prescription, looks them in the eye and tells them to follow orders. And it’s no secret that fitness centers are a great business because of the high recidivism rate of subscribers to these centers (more than 50 percent drop out).

3. Many people dig their graves with their own teeth, hence, the obesity epidemic, which has now reached worldwide proportions.8 That’s why obesity is replacing smoking as the poster child for preventing chronic disease, and health plans will be paying members to join Weight Watchers and similar organizations.9

4. Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

5. Modern technologies--cars, home computers, video-games, TVs, etc.–confine movement and foster obesity. These technologies are part of the culture and are beyond the physician’s influence. Add to these technologies junk food, transfats, absence of suburban sidewalks, lack to time to exercise, and you compound the outcome problem. To paraphrase James Carville, when it comes to obesity outcomes, “It’s the culture, Stupid!”

Doctors aren’t Blameless

Doctors aren’t blameless for poor outcomes or for failing to follow guidelines. It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

Doctor-patient education outside the office is beginning to take off. Two examples spring to mind:

1. Emmi Solutions, founded in 2002 by a Chicago urologist, David Sobel. The company provides online interactive programs of what to expect from surgical procedures and chronic disease episodes and gives them to patients and their families to view at their leisure at home.

2. EDocAmerica, founded in 1998, by Charles Smith, a family physician and medical director at the University of Arkansas medical center in Little Rock. His company, staffed by 12 national family physician leaders, uses the Internet and email to “prescribe” healthcare information for employees of large groups about their health care options.

Compelling doctors to follow guidelines and enforcing their compliance is not as easy as it might seem. Whose guidelines? Keep in mind there are more than 2,000 guidelines floating around out there. You may find them at the National Guideline Clearinghouse website ( These guidelines depend on both evidence and opinion and are neither infallible nor a substitute for clinical judgment.

Doctors are mortal and may have a hard time keeping all these guidelines in mind. Small wonder that adherence to guidelines and outcomes vary. As I outline above, patient behavior outside of the office and hospital settings is an important factor in healthcare outcomes. Doctors can’t be held solely--or even primarily--responsible for outcomes, and rewarding or punishing them for outcomes may be overly simplistic.

Doing so in the confined hospital setting may make P4P advocates “feel good,” and it is a good place to start, but P4P may not lead to better long-term outcomes.
Quality, outcomes and metrics to measure the relationships among these three are very much the buzz these days, especially in hospital, health plan and Medicare circles. Often the blame for poor outcomes falls on doctors.

What this buzz fails to address adequately is failure of patients to comply with doctors’ instructions and to change unhealthy behavior when out of the doctor’s immediate sphere of influence.

Perhaps Rodney Hayward, M.D., from the VA Ann Arbor Health Services Research and Development Center of Excellence and Schools of Medicine and Health at the University of Michigan, says it best: “The last thing we need is a performance-measurement system that encourages a little improvement in quality and a substantial increase in costs.... The value and importance of most medical treatments vary tremendously among patient populations in complex ways.... Until our performance-measurement system is based on clinically relevant information and targets high-priority care, performance measurement is likely to remain a great idea that is more of a distraction than a benefit.”10

A Few Final Points

--P4P may be “fundamentally a social experiment likely to have only modest incremental value.”3
• P4P is an experiment worth conducting in hospitals.
• The closed hospital environment is a good place to start because it addresses high priority clinical problems.
• Doctors in hospital practice should follow existing quality indicators.
• P4P in outpatient settings will be hard to implement and is unlikely to improve outcomes.
• Berating physicians for high costs and poor outcomes is a counterproductive strategy.
• Rewarding physicians for what they are professionally obligated to do in the first place may be an unrewarding and counterproductive strategy.
• Resistance to behavior change among patients is significant and makes long-term P4P measurable outcome improvement unlikely.
• Outcomes depend heavily on cultural factors.
• Resources devoted to prevention and wellness are more likely to be effective in improving outcomes than P4P.


1. MMA Quality Review: “Physicians in Pursuit of Excellence,” Winter, 2007.
2. Lindenauer, P., Remus, D., Roman, S., Rothberg, M., Benjamin, E., Ma, A., and Bratzler, D., “Public Reporting and Pay for Performance in Hospital Quality Improvement,” New England Journal of Medicine, volume 356, pages, 486-496, 2007.
3. Epstein, A., “Pay for Performance at the Tipping Point,” New England Journal of Medicine, volume 365, pages 515-517, 2007.
4. Rosenthal, M., and Frank, R., “What is the Empirical Basis for Paying for Quality in Health Care,” Med Care Res Rev, 63:135-157, 2006.
5. Peterson, L., Woodard, L., Urech, T., Daw, C., and Sookanan, S., “Does Pay-for-Performance Improve the Quality of Health Care?” Ann Intern Med, 145: 265-272, 2006.
6. Landon, B., Hicks, L., O’Malley, A., Lieu, T., Keegan, T., McNeil, Barbarad, and Guadagnoli, E., “Improving the Management of Chronic Disease at Community Health Centers,” New England Journal of Medicine, volumes 359, pages 921-934, 2007, March 1.
7. Squires, C., “Study: Most Diabetics Don’t Exercise,” Associated Press, January 26, 2007.
8. Hossain, P., Kowr, B., and El Nahas, M., “Obesity and Diabetes in the Developing World,” New England Journal of Medicine, 356:313-315, 2007.
9. Spector, H., “Insurer to Pay for Weight-Loss Efforts,” Cleveland Plain Dealer, February 1, 2007.
10. Haward, R.A., “Performance Measurement in Search of Path,” New England Journal of Medicine, 356:951-954, 2007, March 1.

Thursday, March 29, 2007

Videos - The Medium is the New Health Care Message

Taking an Honest Visual Look at Health Care

The medium is the message... There is a basic principle that distinguishes a hot medium like radio from a cool one like the telephone, or a hot medium like the movie from a cool one like TV….Hot media are low in participation, and cool media are high in participation or completion by the audience.

Marshall Herbert McLuhan, 1911-1990, Understanding Media, 1964

Mindset #11 – “Don’t forget the ecology of technology.” The changes that result from the technologically driven onslaught of the visual can have profound impacts on the environment in which you operate and the environment of the marketplace that you address. Ask yourself what in those environments will be enhanced, what will be diminished, and what will be replaced because of the changes.

John Naisbitt, Mind Set! Collins, 2007

I have a dear friend, Brian Klepper, PhD, founder the Center of Practical Health Reform and now executive producer of NCI Talk (, an educational and consulting company specializing in managing health care costs. Brian also has a personal blog ,, which I invite you to read.

The Message

Brian’s focused message is that the two major flaws leading to soaring health costs are fee-for-service and lack of transparency. He believes only the business community and major health care sectors have the heft and leverage to correct these flaws. They can do it , he believes, through use of information technology management systems that compare costs, outcomes, performance. and reward the most efficient providers and suppliers.

His message is two fold to his audiences – use your clout to enforce efficiency measures and to achieve quality management. The audiences include those attending the World Health Care Congress, cancer meetings, American College of Surgeons conclaves, the National Association of Health Underwriters, and gatherings of those who represent health care supply chain vendors. I applaud Brian’s message because it relies on employers and business sides of health care to correct the health system’s flaws rather than the government.

On the hospital side, Brian’s message to hospital executives is honest and sobering. It is this.

A) Hospital revenues come mainly from two sources: government programs (Medicare and Medicaid), and managed care organizations serving as intermediaries and surrogates for employers.
B) Hospital costs spring mainly from two sources: labor costs, supply chain costs.
C) Hospitals are losing ground financially. In an aging population with growing numbers of uninsured and an employer market that is either dropping coverage or dumping costs on employees, patient mix is shifting to the government side of the equation, which pays the least, and away from private sources of payment, which pay more.. .
D) Hospitals can’t do anything about the inevitable demographics, and it can’t do much about the shift of consumers away from the hospital to less costly environments. Nor can the hospital do much about rising hospital labor costs, for it needs skilled professionals to remain competitive. But hospitals can do something about its supply chain costs, its most rapidly rising expense and a market in which vendors often have margins exceeding 50%.

NCI Talk Videos

Effectively managing costs is where NCI talk, which might be more aptly called NCI voice views, comes in. Brian regularly tours the country to do video interviews with leading medical visionaries and innovators. Recently, he visited Washington State and Oregon to videotape interviews with multiple health care leaders, both physicians and non-physicians.

Among physician leaders, he interviewed were.

• Gary Kaplan, MD, CEO of Virginia Mason, an integrated health organization in Seattle that has adopted and modified the Toyota lean production model for its own purposes;
• John Kitzhaber, M.D. two time governor of Oregon, who is deep into devising a universal means-tested plan for Oregon that regulates public but not private coverage;
• David Lynch MD, of Bellingham, Washington, who heads up a group of 50 doctors with eight or nine medical offices covering a population of 170,000 and “doing all the right things” to offer safe, effective, and best practice care.

What’s Different about NCI Approach

To me what’s different and innovative about the NCI approach is its talk show approach. This approach consists of integrated videos featuring three expert guests talking on a single topic; a seasoned talk show moderator; a mini-documentary based on one of Brian’s visits and directed towards the audience of interest; and a closing video by Brian summing up the implications of what has been said

Under the rubric of “Taking an honest look at healthcare,” these videos are presented to health care conference audiences on subjects like comprehensive cancer care, proactive pay for performance programs, quality management, greater efficiencies, and rationalizing supply chain costs.

The Medium is the Message

NCI with Brian as its executive video producer is on the right track. To use John Naisbitt’s words, “a visual culture is taking over the world.” In a culture dominated by video games, TV, Internet images, cell phone and Blackberry pictures, and YouTube, this visual approach has profound and broad implications beyond health care. Naisbitt lists eight manifestations of a visually dominated world.

1. The slow death of the newspaper culture
2. Advertising – back to a “picture is worth thousands of words”
3. Upscale design of common goods.
4. Architecture as visual art
5. Fashion, architecture, and art
6. Music, video, and film
7. The changing role of photography
8. the democratization of the American art museum

In health care, visual forms of communication – animation and voice-guided online interactive programs featuring illustrations and simple language- may soon replace or at least supplement powerpoint presentations. Everyday Americans listen to 25 million powerpoint talks, and many, including myself, are growing weary of bullet points. Subconsciously, whether we’re aware of it or not, many of us now may be wearing bullet-point protective vests. Many will welcome straight talk, clear pictures, and moving images to tell the story

Wednesday, March 28, 2007

Government care -Medicare and the VA

Less “Universal”Than Meets the Eye

Yesterday I visited a relative in a “skilled nursing facility,” The facility is a one story sprawling brick structure holding 120 patients. It has four wings, each staffed by four aides and one LPN for each 8 hour shift. Medicare covers most patients. You can stay for 100 days under certain conditions.

Otherwise you pay $9000 a month. I don’t quibble with the expense. Aides, nurses, physical therapists, pharmacists, and doctors work hard caring for mentally or physically disabled, often incontinent patients. Caring for these patients requires expensive equipment – monitoring devices, portable toilets wheel chairs, machines for lifting patients in and out of bed.

My Relative – a 73 Year Old Veteran

My relative is a 73 year old veteran. He receives disability from a back injury incurred while in the service. For the last 20 years, he has received care off and on from the VA. He suffers from Lewy Body disease, a variant of Parkinson’s disease that often ends with dementia. He has been hospitalized six times in the last year with aspiration pneumonia, has insulin-dependent diabetes, and suffers from chronic bronchitis and emphysema. He receives 40 pills daily, can’t walk and talk, and has trouble feeding himself.

Medicare Rules and VA Bureaucracy

Come next week, unless he shows progress, Medicare will force him to leave the nursing facility. His wife can’t afford the $9000 it will take to keep him there.. She has thought of the VA as an alternative. She has called the VA multiple times and listened to its lengthy telephone menu, but has yet to connect with a human voice. She has, she believes, hit a bureaucratic brickwall. She fears there’s no way through it or around it. But the Parkinson’s Foundation assures her, under the right circumstances, the VA will provide home care benefits. I’ve tried to help by googling the VA Office of Geriatrics and Extended Care. It has 250 Frequent Asked Questions, and a comment box where you can seek help.

The Question – What Lies Ahead Politically ?

My admittedly fleeting experience in the skilled nursing facility and the VA raises this question in my mind: What do existing government “universal” programs portend for future “universal coverage?’ I can’t help but reflect on what the present presidential candidates are promising.

On the Democratic side,

• Former senator John Edwards promises universal coverage and would pay for the estimated cost of $90 to $120 billion by raising taxes on the “wealthy.”
• Senator Barack Obama doesn’t have a detailed plan but says he “would create a political consensus around the need to solve the problem.”
• Gov. Bill Richardson would offer tax credits to help buy insurance and extend Medicare to cover those from 55 to 64.
• Senator Hillary Clinton would ”end price gouging, cost-shifting, and unconscionable profiteering..”
• Senator Christopher Dodd would forge a consensus to cover all Americans and raise taxes.

Most Democrats say they would raise taxes on “the rich” to pay for universal care. Other than public resistance, there’s one small nagging problem with raising taxes. As Presidents John F, Kennedy, Ronald Reagan, and the present president George Bush have shown, the surest way to raise government revenues to pay for social programs is to cut taxes. It works every time. Another problem is that existing government programs often produce waiting lists. My relative’s wife says she has been told she will have to wait for 2 years before her husband would qualify for a VA geriatric unit – which will of course be too late.

But let there be no doubt. Democrats “own” the health care issue, which accounts for their confidence in their rhetoric about universal coverage. You see, unlike the Republicans, they have this “plan” called “universal coverage.” Never mind the details about extraordinary costs of such programs (the Johnson administration said in 1965 Medicare would never exceed $9 billion, today it costs over $250 billion), the miserable service record , the inevitable waiting lists, the archaic VA facilities, and the endless impregnable bureaucracies. Besides, Democrats know universal coverage “polls fabulously” – who doesn’t want “free’ government coverage financed by the “rich?”

The Republicans? Well, the public doesn’t trust them on health care. Americans –frenetic, fearful, and furious -- over spiraling health costs, simply will not listen to complicated arguments about incremental change, or constant innovations, no matter how good these changes or innovations promise to be. Governors Arnold Schwartzenegger and Milt Romney have swaggered forth with “universal-lite” state plans heavy on regulation and taxes, targeted on health plans and providers, and payroll taxes. Polls favor these initiatives.

Troubles on the Horizon for State’s Universal Coverage

There are trouble signs on the horizon for these state plans. Health care and small business lobbies vigorously oppose being the “fall guys” for politically ambitious governors. State plans are already projected to cost much more than originally planned.

In Massachusetts, government spending will be $276 million rather than the $151 million promised. And premiums for uninsured workers will be $380 per month rather than the promised $200, amounting to as much as 6% of their income.

In California, the plan will cost $12 billion, in addition to the taxes on hospitals, doctors, and small businesses.

The biggest problem for Republicans is that they have no clear comprehensive Grand Plan for alleviating the cost and coverage crisis. Dr. Tom Coburn ( R.), the senator from Oklahoma, is said to have a bold plan, based on fundamental, bottom-up reforms cast in the language of markets, consumers in control, revamped tax codes favoring individuals, and health savings accounts, but his plan has yet to reach the level of widespread public consciousness.

A Sad Ending

Sadly, none of these future “universal plans,” as put forth by either political party, or the existing “universal coverage” systems of Medicare or the VA, will help my relative – or his wife -- pay for his end of life illness. Given his helpless condition, and his wife's inability to care for him there, he won’t be going home again. Where he goes, no one knows - and no one knows who pays.


1, Pear, Robert, Candidates Outline Ideas for Universal Health Care, New York Times, March 25, 2007.
2. Bellick, Pam, Massachusetts Sets Benefits in Universal Health Care Plans, New York Times, March 21. 2007/
3. Pipes, Sally, Intensive Care for RomneyCare, Wall Street Journal, February 26, 2007
4. Strassel, Kimberly, Republican Rx: GOP Alternatives to Hillary Care, Wall Street Jounral, March 23, 2007.
5. Finkelstein, Amy, The Cost of Coverage, Wall Street Journal, February 28, 2007.

Tuesday, March 27, 2007

Home care, healing environment - As Much As

As much as I enjoy reading in the Wall Street Journal
That future hospitals will be healing places,
I know
There’s no place like home,
As a healing spot to go.

As much as I like the concept
That hospitals will offer home-like amenities.
I feel
There’s no place like home,
As a space to heal.

As much as I love the idea
That hospitals will be healing environments,
I maintain
There’s no place like home,
As an oasis for health to sustain.

As much as I admire the theory,
That hospitals will have no noise, no harsh lighting,
No sharp corners, no environmental stresses,
I believe,
There’s no place like home,
As a chamber for pressures to relieve.

As much as I embrace the hypothesis
That hospitals will have social spaces, gardens,
Acoustical tiles, odor filters, and natural light,
I insist,
There’s no place like home,
As a natural ecology in which to exist.

As much as I know home care isn’t always possible,
That hospitals are needed for adverse conditions,
I pray,
We can make hospitals like home,
As pleasant infirmaries to keep diseases at bay.

As much as I acknowledge the need for care
That hospitals and other institutions supply,
I fear,
Most these dreaded words,
You won’t be going home again, dear.

There’s no place like home.
Unless you need to be in the hospital,
Which, if hospital designers have their way
Will become more like
A home away from home.

1. Laura Landro, Hospitals Set Blueprint for a Better ‘Healing Environment,’ Outdated Facilities Redesign Patient Areas to Lift Quality of Care, Wall Street Journal, March 21, 2007

Monday, March 26, 2007

Innovation-Driven Care, Herzlinger -The Gospel According to Harvard Business School:

Prologue: What follows are thoughts about the influence of Regina Herzlinger, PhD, professor of business administration at the Harvard Business School on consumer-driven health care. These thoughts don’t necessarily represent the philosophy or activities of the Business School as a whole. Another Harvard Business School professor, Michael Porter,for example, has made quite a splash with Redefining Health Care: Creating Value-Based Competition, co-authored with Elziabeth Olmstead Teisburg.

In any event, here goes.

We are the music-makers,
And we are the dreamers of dreams,
Wandering by the lone sea breakers,
And sitting by desolate streams
World-losers and world-forsakers,
On whom the pale moon gleams;
Yet we are the movers and shakers
Of the world forever, it seems

Arthur William Edgar O’Shaughnessy,
Ode, 1844-1881

This week the March 2007 Harvard Business School Alumni Bulletin crossed my desk. The front cover referred to an interview with Daniel Vasella, MD, “Medicine Man: Novartis CEO Daniel Vasella Makes All The Right Moves.”

As a medicine man, Vasella is an unparalleled mover, shaker, and pill-maker. Three years ago he was named “the most influential European businessman of the past 25 years” in a Financial Times poll of 4000 executives. For good reason. Just this year, Novartis net income rose 17% to $7.2 billion in 2006.

I am personally no mover and shaker as a business person, but I will always be indebted to the Harvard Business School (HBS), of which I am a quasi-alumnus, having graduated as a member of one of its eight-week advanced management programs.

Here, in three parts, are why I'm indebted to HBS.

Part One – Indebtedness – Regina Herzlinger Foreword to Innovation-Driven Health Care (Jones and Bartlett, 2007)

• I spent eight weeks at HBS in 1976 as a student in a program, “Health Systems Management, “ jointly sponsored by the Harvard School of Public Health. It was there I met Regina Herzlinger, PhD, now professor of Business Administration. We have maintained contact off and on for the last 30 years, and she was kind enough to write the following flattering foreword to my book, Innovation-Driven Health Care (Jones and Bartlett), coming off the press on March 29, 2007.

Richard (Dick) Reece is that rare breed of physician commentator who admires his colleagues. How long has it been since you read an article in a medical or health policy journal that applauded the skill and compassion of doctors, scientists, and administrators and/or bemoaned their increasing loss of autonomy to health insurers and governments? Well, you won’t read about how greedy and incompetent they are in Innovation-Driven Health Care: 34 Key Transformations in U.S. Health Care.

What you will read is an intelligent, knowledgeable analysis of the impact of innovations on the future of U.S. health care—and supportive, too. As Dick says, God love him, “being a physician is being part of a brotherhood or sisterhood.”

But why should you read yet another health care future book? Because Dick Reece has nailed it: His view of the future is exactly right. If you want to continue doing what you are doing, this book will enable you to assess how you fit into this new world and to adapt yourself if needed.

I had the good fortune to meet Dick Reece some 30 years ago at the Harvard Business School’s Program for Health Systems Management. Then, as now, Dick was a big man with a gruff affect, piercing intellect, heart of gold, and a sunny, bemused view of life.

I learned of the qualities because I taught accounting in the program, a course that quickly separates the intellectual and emotional wheat from the chaff—the analysts from the analyzed; the “let’s-cut-costs” types from the “let’s–increase-productivity” ones; and those with a sense of humor—believe me, you need this quality in an accounting course—from the deadly serious.These qualities inform Innovation-Driven Health Care.

However, Dick is not merely a cheerleader. He believes that innovations will increase the productivity of the U.S. health care system so that it can provide better services, at a better price, to more people. What a contrast to the usual dour prescribers who contend that innovation is impossible and improved productivity a myth. Their cure? Uncle Sam rations health care. Hello, Canada!

To make the importance of this point of view concrete, consider the following excerpt (Califano, 1977):

Almost immediately (after the introduction of CAT scanning), political objections arose to widespread use of this new imaging technology. HEW Secretary Joseph Califano rose on his political haunches and declared, “There are enough CAT Scanners in Southern California for the entire western United States.”

Not to be outdone, Dr. Howard Hiatt, dean for the Harvard School of Public Health, compared the use of CT scanners to overgrazed medical commons in which too many were foraging for too little. He said a national center for technology assessment and suppression of new technologies should be established and argued (1976):

There is no doubt that the scanners provide additional diagnostic information, and frequently with less discomfort and hazard to the patient, however, it is not clear that the diagnostic information very often leads to a better outcome for the patient. Until this important information is available from careful studies, would we not be better served limiting the use of such expensive technology.

Califano and Hiatt overestimated the power of federal regulations and underestimated the thirst of doctors and the public for this clearly superior technology. Neurosurgeons immediately embraced CT scans. Their enthusiasm soon spread to orthopedic surgeons, who saw the potential of MRIs for joint, bone, and soft-tissue imaging. Most recently, oncologists have welcomed PET scans to check for subtle cancer spread. CT and MRI scanning has become the modus operandi for evaluating all manner of physiological anomalies.

In 2001, 225 internists, when asked to evaluate the relative importance of 30 medical technologies, rated CT and MRI scans as the number one innovation.”

However, Reece is no ideologue. He is a pragmatist. With illuminating case studies, he provides news you can use, as illustrated by the following examples:

How stand-alone, onesie-twosie physician practices can thrive.
• Want to leave medicine? Here is how to make your intellect, training, and experience work for you.
• How to empower consumers and embrace new high-deductible health plans without disemboweling yourself.
• How large groups—Mayo, Kaiser—have avoided “mid-life” crises.
• How to flourish in insurer-physician and hospital-physician relationships, which are more typically akin to the relationship between a salmon and a bear.

I have merely mentioned only five of the 34 topics in this book. If you want to know more, read on!

Why am I so sure that Dick Reece’s views of the future are right? It’s not only that he agrees with my own views, but also, and, more importantly, because he has been right so often before. For example, a dozen years ago, as chairman of a physician hospital organization, Dick created the case-based pricing that payers are finally coming to, some 20 years later. And while living in the midst of managed care–loving Minnesota, Dick predicted the threat HMOs posed to physicians. The observation, which now seems obvious, was radical when he made it—a quarter century ago.

Best of all, Dick’s sunny belief in the transformative powers of innovation are mirrored by his bright, witty writing style. Here are some samples:

Question: What do you call farmers who convert fallow into fertile ground?

Answer: Farmers with a sense of humus.
And on pay for performance: “An ounce of performance is worth a pound of lucre.

It’s great to laugh, especially when the laughter is accompanied by such useful.

Part Two – Indebtedness – Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers ( Jossey-Bass, 2004)

In 1999 Regina invited me to attend a conference “Consumer-Driven Health Care” organized by Harvard Business School. Ultimately the papers presented at that conference became the basis for her book Consumer-Driven Health Care: Implications for Providers, Payers, Policymakers (Jossey-Bass, 2004). Speaking of the Gospel , in the future this 892 page tome may well be the cited as the gospel that lay the foundation for the consumer-driven movement that was to follow.

Regina served as editor of the book. It had 97 contributors, of whom 25 were physicians. She clearly understood physicians would be central figures in shaping consumer-driven care. As I look back and leaf through the list of contributors and attendees, I realize most movers and shakers of today’s health care world were there and are still around, moving and shaking and developing what is to become a uniquely American system, a blending of private, public, and governmental enterprises.

In 2004, Regina and a Harvard colleague wrote an article in the Journal of the American Medical Association (“Lessons from Switzerland,” volume 292, pages 1213-1220). The article said, in essence consumer-driven care and universal coverage can co-exist. Here is the abstract of that article:

Switzerland's consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employer-based US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.One of Regina’s “students” in the 1999 Harvard conference was Daniel (Stormy) Johnson, MD., a radiologist, former president of the American Medical Association, and now Board Chair of Consumers for Health Care Choices (CHCC).

In a March 15, 2007, press release, CHCC president, Greg Scandlen, issued this statement:

American Media Ignore Swiss Vote

Single Payer Rejected by 71% of Voters

On Sunday the Swiss people voted overwhelmingly to reject a Single Payer system. But there has been not a word about it in the American press – other than a single paragraph in the trade publication Business Insurance.

The vote was on whether to replace Switzerland’s current system of mandatory health insurance coverage provided by 87 private health plans with a single payer system based on income-related premiums. It was rejected by 71% of the voters.
If the vote had gone the other way – if the Swiss had embraced Single Payer – it would have been front page news in every newspaper in the United States, it would have been a lead story in every broadcast. Reporters would have booked flights to Geneva to interview citizens and political leaders.

This provides a sobering example of why public policy goes so wrong in the United States. The public is informed of only one side of the story. Reporters and editors are biased in favor of government intervention and against free markets. They are part of a privileged elite who think consumers are incapable of making sound decisions and intelligent choices.

But the people of Switzerland made the same choice as the American people make every time they have had an opportunity. Voters in Oregon rejected Single Payer by a vote of 79% to 21% in 2002. People do not want to be herded into a government-run cattle car. We want and demand freedom of choice in health care as in every other aspect of our lives.

• Part Three – Indebtedness – Daniel Vasella, MD, Interview

Lastly I am indebted to Harvard Business School through its publications for continuing to recognize that health care is a driving, uplifting force in the U.S. and international health economies. Indeed, within 20 years, health care may be the economic engine for 25% of the U.S economy, as it already has in Minnesota, where it is that state’s number one employer.

The interview highlights the insights and contributions of Dr. Daniel Vasella, who rose from a clinician in Bern, Switzerland, to work his way up through the marketing division of the Swiss conglomerate Sandoz. Within a decade, Vasella, who did a stint at Harvard Business School advanced management course in 1989, was leading Sandoz’s merger with Ciba-Geigy. The merged company was named Novartis. Vasella became CEO of Novartis in 1996. Today, Novartis ranks no. 4 among international drug companies with sales of $37 billion. Under his leadership, the company has led the industry in new drug approvals. It now has 138 new drugs in its pipeline. Novartis has also diversified into vaccines and generic drugs, setting it apart from rivals.

Among the observations and insights Vasella offers in his interview are these.

• Drugs make up 15% to 18% of health costs but account for about 40% of the drop in disease mortality. If we were to strip all the profits from the industry, it would drop overall health costs by just 3%.
• The Medicare prescription drug program has been a success, despite Democratic criticisms that it relies too much on private insurance providers. Costs have been lower than anticipated, and, says Vasella, “The system seems to work pretty well.”
• Novartis has succeeded in developing new products by creating a culture of innovation by integrating research and marketing and by nurturing project teams to move drug development forward.
• Novartis has moved its research headquarters to the U.S, so it work more closely with academic institutions, has created a genomic institute in La Jolla, and in 2002 formed the Institutes of BioMedical Research in Cambridge, Massachusetts.
• Novartis has invested heavily into generic drugs. These drugs have less profit than brand names but are growing more rapidly. People are rapidly switching from brand drugs to generics to cut expenses. “Our philosophy is to link for sustainable growth and to create and maintain a business that is competitive and that satisfies the needs for society and customers.”
• Novartis has moved into vaccines big time because of high growth rates of 15 to 20% and because other companies had abandoned vaccines due to litigation problems. This adversarial legal climate has changed recently, The U.S. government has recognized nobody wants to produce vaccines anymore and loosened litigation rules,
• Novartis is cautious about supplying low-cost drugs to poor countries because it cannot fix poor governance, corruption, inadequate distribution systems, and lack of health-care professionals. Even so, Novartis is delivering services and products worth $700 million to these countries, about 2% of its sales. Vasella says one cannot punish patients because of bad government, but it is not the responsibility of private companies to compensate for bad government.


Regina Herzlinger, PhD, Professor of Business Administration at the Harvard Business School, has helped nurture a group of physician movers, shakers, and pill-makers to lead consumer driven health care. This type of care may develop into an integral component of U.S. and international health systems. Consumer- driven care assumes empowered consumers will have more choice, more control over care, and lower costs with higher quality. It also takes for granted consumers will willingly take more responsibility for their health and will become more informed health care consumers.

Sunday, March 25, 2007

Fog index - Medical Jargon: Measure It, End It, Create It

Jargon -- SPECIALIST LANGUAGE that is used by a particular group, profession, or culture, especially when the words and phrases used are not understood or used by other people.

Encarta World English Dictionary, St. Martin’s Press, 1999

Herein lies two “how-tos.”

1) How to measure and end medical jargon when speaking or writing for patients. I call this process “jargonoughting.”

2) How to create medical jargon to impress your fellow physicians. I call this process “jargonauting.”

I do this because I believe one fundamental innovation that will change health care will be translating medical jargon into language patients can understand. This will facilitate patient education, overcome patient illiteracy, make medicine more effective, and reduce misunderstandings between doctors and patients.

Michelle Sobel leads a creative team at Emmi Solutions. This Chicago company produces interactive online visual programs narrated in plain words to inform patients what to expect from surgical and chronic disease episodes. Michelle has mastered the art of converting medical jargon into plain language. The language in the Emmi programs are phrased and written at the sixth grade level.

But how, you may ask, can I, as a doctor, be sure I’m writing at the sixth grade level? I don’t know Michelle’s secret. But as for me, I measure my jargon by using the Fog Index. Yes, the Fog Index? In 1968 Robert Gunning, a consultant who advised publications how to write in language people understood, devised this numeric index.

To find the Fog Index of a piece of prose:

1) Calculate the average number of words in your sentences (or complete thoughts linked by punctuation marks);

2) Count the number of three syllable words per 100 words (don’t count proper words, combinations of short words (e.g manpower) or verb forms made into three syllables by adding –ed, -es, or –ing.)

3) Add 1 and 2 and multiply by 0.4 to get the Fog Index.

Let’s say the Fog Index is 6. Six reflects the grade level it takes to read with ease a given passage.

Jargonought, and Fog Index

To give you a feel for the Fog Index, let’s count it for a well-known biblical passage.

I returned and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise. nor yet riches to men of understanding, nor yet favor to men of skill, but time and chance happen to them all.

Fog Index

1. 7-8-6-7-6-7-8=49/7=7.0
2. 1=1.0
3. Fog Index= 7.0+1.0 x 0.4= 3.2

Now let’s take a GI group’s paper instructing a patient how to prepare for an intestinal endoscopy exam.

These are instructions for your endoscopy preparation for tomorrow in the operative suite at our endoscopy facility. You are now scheduled to have an examination of your lower and upper intestine with the use of a lighted flexible tubular instrument called a endoscopy scope. You will be administered medication prior to your examination that will enable your physicians to perform the test with as little discomfort to you as possible. Please be aware of the medication's sedative properties. Because of these sedative effects, you must make arrangements for someone to accompany you home or to your apartment or condominium after the procedure.

1. 17-27-26- 8-24= 102/5= 20.4
2, 102X 29/91=28.4
3. Fog Index = 20.4 + 28.4 X 0.4 =19.5

Using the Jargonought technique, this passage's Fog Index could be reduced.

You are scheduled to have an exam of your colon and upper bowel., We will use a lighted tube called an endoscope to do this. You will be given a drug to put you at ease. This drug will sedate you. So we ask you bring someone to drive you home.

1. 13+12+5+10 = 10.0
2. 1= 1.0
3. Fog Index= 10.0 + 1.0 X 0,4 = 4.4

Jargonaut, Or Mixing Wind and Fog

Where do physicians learn to use jargon? They learn it in medical school. Jargon is a contagious disease. Doctors catch it early on in academic medical centers where the “public or perish “ phenomenon flourishes. Then jargon spreads, becomes endemic, then epidemic as doctors seek to impress one another. Unfortunately jargon is hard to stamp out, and doctors may lapse into using it when talking to patients.

To show how to practice jargonaut, and to become a jargonaut, I wrote this piece for the Journal of the American Medical Association.

Space-Occupying Gambits for Medical Writers

As a rule, disease as it stalks through the land cannot keep pace with the incurable vice of scribbling about it.

John Mayo, de Rachitide, 1668

Space-occupying prose diffuses through medical writing like a fog. Yet space-consuming efforts of some of us continue to be rejected. The message of this essay is that obscurity, when properly inflated, can lead to publication. Your goal is clear – to produce the greatest number of papers from the minimal amount of data using the maximal number of words.

Windfoggery Weave

Windfoggery is the bedrock of all obscurity. Wind and fog don’t coexist in nature. But they can be woven together on the printed page. Give the reader a low-fact diet with high-jargon content. Sprinkle with polysyllabic words. Scramble the syntax. If you doubt a predecessor’s methods, don’t say: “Jones’ methods are questionable.” Deepen the fog, and raise the wind velocity by saying: “The quantitative variables assayed by Jones were analyzed and scrutinized and appeared, according to our interpretations, to demonstrate significant fluctuations, which seems to vacillate diurnally.” Note the murky merging of wind and fog.

The Retrospective Ramble

In the retrospective ramble, pay homage to the past by exhaustively reviewing your subject, The flood of references will inundate the editor and drown the reader. Refer to inaccessible, outdated, or foreign journals. This adroit maneuver discourages and diverts critics. Their futile search through back alleys of print will wear down objectivity. It will blur perspective. Complete your conquest over comprehension by quoting everything ((or nearly everything) that has been said about your subject. Whether the material is relevant isn’t important. It’s the number of references that count. It’s wise not to be discretely excessive. The discerning editor will quickly reject such a clumsy effort as this.

“I 26,31,14 believe that21,88 this technique25,85,99 of using excessive references 922 to previous papers is abused 71,02, 502 by most authors, 28,192,617 particularly myself1,22,3581,269 in my exhaustive reviews of articles, 67-84 all of which have been rejected by numerous journals.0

The Humble Hedge

The humble hedge is a gambit whereby you qualify your meaning into nothingness while appearing to be objective. Always convey doubts about your statements. Arrange a retreat from clarity with hedge verbs like indicate, suggest, appear, may, and might. Withdraw with these nouns: speculation, conjecture, theory, and hypothesis. Hedges can be classified as first, second, and third order or as single, double, and triple barreled. A fourth-order or quadribarrelled hedge is clumsy and should be avoided. A fifth-order hedge, such as “Speculation about etiological factors might possibly suggest that previous investigators may have been wrong some of the time.” is excessive and poor form. The sentence could be reduced to a third-order hedge with only slight loss of ambiguity.

The Passive Ploy

In the passive ploy, place yourself in the background. Stress vague pronouns, fuzzy facts, and lofty concepts. To do this, write in the passive voice. You can add words, befog your meaning, and become a detached sage. It was discovered by the author is nearly 4 ½ times longer than I found and is more humble. It was reported by this investigator in a recent publication requires eight times more space than I noted and is more sedate. But, how, you may ask, can I be sure I am writing in the passive voice? You could consult books of grammar, but most doctors are too busy for that sort of thing. So I have gathered together some practical suggestions.

• Commence you sentences with impersonal remarks –It is though, it is believed, it is felt.• Strip your sentences of verbs which picture or imply action .
• Glue your thoughts together with have, seem, or some form of to be – is, are, was, were.• Delete the personal pronouns – I or we.
• Strew your sentences with whichs, bys, or ofs.

The passive voice allows you to avoid straight statements. The true scientist is never direct or blunt. Use the passive voice often. It is the most space-occupying weapon at your command.

The Word Wedge

Word wedging is art of forcing big words into sentences where they don’t belong. The careful wedger picks his tools. He prefers abstract terms with scientific overtones – armamentarium, congeners, continuum , dynamic, esoteric, kinetics, methodology, modality, oncogensis, parameter, sophisticated. If the wedger is clever, he will drop bureaucratic buzz bombs by intermixing any of the following words in these three columns in any combination.

1 2 3
total management care
regional supportive coordinator
universal health analyses
primary integrated centers
comprehensive ambulatory services
national resource priorities
quality pilot planning
interdependent involvement needs
preventive paramedical studies
systematized effective utilization
feasible digital implementations
delivery scientific objectives
unmet outreach systems
community multidisciplinary maintenance
centralized medical parameters
longterm multiphasic feedback

The following example of wedging if from an article in a well-known medical journal,

Substances which are immunologically foreign are composed of autohochthonous materials. These are not diagnostic, but with progressive increase as seen by serial samples, in association with other suspicious parameters, electrophorectic pattern may become significant as a predictor.

Observe the passive mingling of windfoggery, hedging , and wedging – all combining to produce hieroglyphic obfuscuity.

The “That” Thrust

Put this gambit into play by thrusting the word “that” into the start of your sentences. With “that,” you can introduce your sentences, qualify your thoughts, blunt your meaning, express wonderment, and consume thought. Let me show what I mean with these examples – It is fascinating to note that, in spite of the fact that, It is often the case that, But it may be possible that, There can be little doubt that, It is interesting to observe that. Not the running start. Each example consists of six word obstacles the reader must traverse before he reaches the beginning of the sentence. Think of “that” as a suitcase word. Whenever you use it, you carry along verbal baggage, and “that,” after all, is your mission – your main game.

The Verb Void

Save this gambit for your first revision (a second revision is rarely necessary in jargon-filled space –occupying writing). Read over your paper. Look for verbs that can be changed into nouns, Void your sentences of vulnerable verbs. Then rearrange the entire sentence. Study these three examples to see how they gambit works.

Before Revision – Then we decided to explore the other possibility (8 words).

After Revision – Then the decision was arrived at that an exploration of the other possibility was advisable (16 words, 100% increase.

Before Revision – We investigated what causes cells to mutate (7 words).

After Revision –We then made an investigation of what the causes were for the mutation of the cells (16 words, 130% increase).

Before Revision – Surgeons enlarge the cavity by incising laterally.

After Revision –The best means for enlargement of the cavity by surgeons is by means of a lateral incision (18 words, 160% increase)

As a beginning gamesman, you’re no doubt impressed most by the increase in the number of words. With experience, you will realize another virtue of the verb void – it breeds other gambits. In the last example above, the passive play came into play. Finally, the act of trading active lean verbs into edematous, sedentary nouns is always good gamesmanship.

The Double Dawdle

The double dawdle permits the gamesman to double his world volume while keeping his facts constant. This gambit has two variations -- the supersuperlative dawdle and the redundant dawdle. Execute the supersuperlative dawdle by adding the words very, markedly ,tremendously, much, quite to your adjectives. If you’re describing a big uterus, you can call it a very enlarged uterus, a quite enlarged uterus, a markedly enlarged uterus, a tremendously enlarged uterus, or a much enlarged uterus. Beware of the triple or multiple dawdle. A “very much markedly enlarged uterus of tremendous size” wouldn’t likely slip through the editor’s net. Only you and the reader will appreciate the profundity of your distinction. Perform the redundant dawdle by joining such words as equal halves, hazardous risks, linear lines, and tumor masses. You appear to be reinforcing your meaning, but you are really just duplicating words.

The Paragraph Parry

When you have a large space to fill, word gambits are good, but paragraph parries are better. Open your paragraph by sallying forth with a decisive sentence. The reader, caught off guard, will plunge into the paragraph. Immediately parry with a series of indecisive sentences. What you give away in your opening, take back in the discussion. Begin with courage. End with prudence. What more could be asked from a dignified scientist. Here is an example of a paragraph parry.

I define cerebral palsy as any paralysis, weakness, or incoordination, or dysfunction resulting from brain damage. Jones, however, regards cerebral palsy as and condition characterized by paralysis, weakness, incoordination , or other derangements of motor function due to pathology of motor control centers of the cerebral cortex. On the other hand, Smith’s definition is more comprehensive, “Cerebral palsy is a condition occurring from birth trauma and resulting form interference with the motor system and leading to neuromotor dysfunction, psychological aberration, atypical convulsions, and behavior disturbance of organic origin,” It is obvious that the brain is a complex organ subject to varying degrees of damage which are manifest in unusual disturbances interpreted in various fashions by different, independent observers.

The writer’s opening sortie is a crisp definition. He then counters with two meandering redefinitions and completes the gambit by admitting hopeless confusion.

Finishing Finesse

Employ the finishing finesse in the backwaters of the discussion and in the stagnant summary. Only the able gamesman should handle this gambit, for he must manipulate ideas that were never expressed. The finishing finesses may be defined as the use of large words in loose phrases to achieve a wandering endings, e.g.

The pathogenesis of the diverse forces operative in electrolyte disturbances were studied, and it was concluded that the variability of the methodology did not permit delineation of the therapeutic modalities.

Observe that the writer ends by hovering above the concrete by talking in abstractions, and the readers ends where he started – fogbound.

I know what you’re thinking – what’s the Fog Index of this essay he just tried to fog by me.

The answer is:

1) 2456/262 = 9.3
2) 346X100/2256= 14.1
3) Fog Index = 8.7 + 14,0 X 0.4 = 9.4

Saturday, March 24, 2007

Clinial innovations - Innovation and Conservative Risk Taking - SHAPE Example

In an earlier blog, I said I would return from time to time to excerpts from The Daily Drucker (HarperBusiness, 2004). This handy little book contains daily entries consisting of excerpts of writings of late Peter D. Drucker, America’s most eminent managerial and social philosopher.

I have patterned mediinnovationblog.blogspot after Drucker’s work. Each day I make an entry based on something I write that day or something I’ve written in the past, always something that relates to innovation in health care.

What follows are: A) One of Drucker’s daily entries; B) One of my daily entries.

A) Drucker Daily Entry

Successful innovators are conservative

I once attended a university symposium on entrepreneurship at which a number of psychologists spoke. Although their paper disagreed on everything else, they all talked about an “entrepreneurial personality, which was characterized by a propensity for risk taking.” A well-known and successful innovator and entrepreneur who had built a process-based innovation into a substantial worldwide business in the space of twenty-four years was then asked to comment.

He said, “I find myself baffled by your papers. I think I know as many successful innovators and entrepreneurs as anyone, beginning with myself. I have never come across an ‘entrepreneurial personality.’ The successful ones I have know all have, however, one thing – and only one ting – incommon: they are not ‘risk takers.’ They try to define the tasks the risks they have to take and to minimize them as much as possible. Otherwise none of them would have succeeded.”

This jibes with my own experience. I, too, know a good many successful entrepreneurs. Not one of them has a “propensity for risk taking.” Must successful innovators in real life are colorless figures, and much more likely to spend hours on cash-flow projections than to dash off looking for “risks. They are not risk –focused”’ they are “opportunity focused.”

ACTION POINT: Determine which of your ideas the least risk and the most opportunity and focus on them.

B) Reece Entry

What I’m about to describe is a remarkable innovation that’s conservative, not risky, and destined for success. It’s a cardiovascular-pulmonary risk device, based on tweaking and modifying the current cardiac risk treadmill stress test but without the risk and with additional pulmonary and predictive risk software.

It’s not risky because:

1) it carries no risk for the patient;

2) it is based on five decades of research;

3) it has been tested and validated at the Mayo Clinic, which is not in the habit of recommending risky devices.

Catching Bad Behavior Early a Risky Proposition

Preventing predictable disease is a risky proposition. You can preach and teach, hector and lecture, fan flames of fear, and even ban bad behaviors in public places. As a general proposition, banning bad behavior is a good thing, but as Oliver Wendell Holmes, Jr. said, “I dare say that I worked off my fundamental formula on you that the chief aim of man is to frame general propositions and no general proposition is worth a damn.”

Nothing, it seems, can change bad behavior for everyone. Banning individual pleasurable behavior in a capitalistic society is a risky proposition, for it impinges on individual freedom. Public banning sound simple, but as alcohol and marihuana prohibition has taught us, defying banning is exciting and often leads to abuse.

Innovative Way to Influence Behavior Leading to Heart and Lung Disease

But there may be an innovative way out. One can measure the early physical effects of bad behavior. After all, whatever can measure can be understood – and managed. That is why the mantra of “metrics” marches through the minds of medical managers. The subjective becomes objective and understandable to common man.


Suppose you had a portable high tech – simple-to-use, economical, low-risk device – that could measure early bad behavioral effects, lack of fitness, early signs of heart and lung disease, engendered by smoking and obesity.

Suppose these “metrics” were objective, reproducible, and understandable to those doing the testing and those being tested. And suppose you could “quantify” chances for hospitalization and even early death, based on a large irrefutable database of hundreds of thousands of patients that have gone before you down the paths of preventable bad behavior. Now, that would be “Innovative,” with a capital “I.”

What I’m building up to is a new technology called SHAPE – Superior Heart and Pulmonary Technology. A group of four (who prefer to go unnamed for now until the scientific evidence is irrefutable) – an electrical engineer, an electrophysiologist, a software programmer, and a health care consultant – known as Cardiac Risk Assessment Associates, have been working in conjunction with the Mayo Clinic department of Cardiology, to develop a physiologically-sound, scientifically-based, and computer-predictive device for evaluating cardiopulmonary disease in multiple settings.

The device will be small, non-invasive, accurate, and will yield reproducible results. The device results from four or five generations of evolving cardiac and pulmonary testing devices. It is evolutionary as well as revolutionary, and it may prove to be effective for detecting early disease, modifying or preventing behavior that led to heart or lung dysfunction, and measuring responses to behavior change or therapy.

Here is how the four associates explain their device.

Cardiac Risk Analysis Associates (CRAA) had developed an advanced cardio- pulmonary testing procedure called SHAPE (Superior Heart and Pulmonary Evaluation). It is non-invasive, convenient, safe, and economical. The test is designed to evaluate and quantify a person’s cardiac and respiratory efficiency not unlike the stressful and risk-prone procedures presently performed in the specialists’ medical offices of today.

The technology represents the next generation of cardio-pulmonary function evaluation. The device includes a stair step, a mask with sensors, an analyzer and a dedicated laptop computer.

The test utilizes inspired and expired gas analysis measured against workload and time. It utilizes newly developed components of pulmonary testing and computerized software and display that result in proxy indicators of organ health and predictive diagnostics.

SHAPE measures the functional “fitness” of a patient’s heart, lung and vascular systems as these organs work together to support activities of daily living, functionality capacity, and one’s capacity for exercise. Its convenience and low costs allows monitoring of therapeutic response to medications, exercise and patient compliance. Additionally, the device is used as a diagnostic screen for cardiac pacing implantation and the calibration and recalibration of such.

The test is a technological advancement over present pulmonary and peak exercise stress testing. As technology advances, SHAPE affords a ‘better, faster, safer, easier, cheaper’ alternative solution to yesterday’s practices. It is designed for use in a primary healthcare setting, utilizing paraprofessionals. It is deemed risk-free and requires a minimum of space while in use or in storage. The device is self-calibrating and requires the patient to perform only a minimum exertion over one’s resting heart rate.

Primary care and health screening is in present need of objective measures of functional heart-lung diagnostics. Present day cardio-pulmonary testing is costly to the system and resides in the domain of the specialists. Early diagnosis and control of obesity and complications due to sedentary life styles are major drivers of costly disease and attendant chronic disease. SHAPE enables early objective classification of preventable disease.

SHAPE provides predictive data for physician evaluation of patient risk for morbidity, mortality and future hospitalization

If you’re like me, you may think of innovation as something new – some revolutionary breakthrough. However, in the real world of health care, most breakthroughs come from evolutionary rather than revolutionary changes, or from combining past technologies to form a new innovation to address some current health crisis.

The Crisis – Deaths from Health and Lung Disease

Consider deaths from vascular or lung disease as that crisis. In 2004, the four leading causes of death were heart disease, 654,092, cancer 550, 270, stroke 150,147, and chronic obstructive lung disease, 123,884. Of these deaths, more than 400, 000 are related to smoking.

The Need for a Device Combining Heart and Lung Testing

These statistics indicate the need for some innovative device to test for heart and pulmonary disease in its early reversible stages, particularly in smokers – the number one environmental preventable cause of death.

Would it not be of great benefit to the health system, then, for some device that had some of the following characteristics?

• Something of no risk to individual subjects while the testing is being carried out.
• Something not requiring the presence of a physician in attendance during testing.
• Something mobile and small that could be used in multiple settings – the physician’s office or a health club.
• Something less expensive than current testing devices.
• Something combining heart and lung testing.
• Something that could measure both cardiac and pulmonary fitness.
• Something sensitive enough to measure early heart or lung damage from lifestyle behaviors that could be stopped...
• Something that could be repeated often and that could measure the response to therapy.
• Something based on large predictive databases that would indicate future risks of hospitalization or death.
• Something derived and modified from existing proven technologies...

Current Common Testing Methods

With regard to the last point,

• The principle device currently used for testing for health disease has been cardiac stress testing, using a treadmill, and sometimes driving the subject to near exhaustion to check for cardiogram changes indicating cardiac ischemia from coronary artery disease. The type of testing carries the risk of inducing fatal arrhythmias while on the treadmill, requires a physician in attendance, requires bulky space-occupying equipments, and lacks sensivity to detect early cardiac and pulomonary diseases in one setting.

• In the office pulmonary testing , physicians often rely upon a spirometer, an apparatus for measuring the volume of inspired and expired air in the lungs. The output produced by a spirometer is called a kymograph trace. From this, vital capacity, tidal volume, breathing rate and ventilation rate (tidal volume x breathing rate) can be calculated. From the overall decline on the graph, the oxygen uptake can also be measured.

What If’s

What if practicing physicians and concerned patients had access to such a small device – consisting of nothing more or less than a stair step, a mask with sensors, a gas analyzer, and a laptop computer – to replace current equipment used for cardiac stress testing?

What if. this device accurately evaluated integrated heart and pulmonary function and distinguished between the two; estimated efficiency of these two vital organs after two or three steps up a stair step?

What if the device yielded an evaluation of heart and lung function within 15 minutes; produced quantitative prognostic information, based on a database carrying information from thousands of previous patients, such as risk of death and risk of hospitalization; could be repeated at will with no risk to the patient; was less expensive than current cardiopulmonary testing; proved to be superior to existing “gold standards” – cardiac ultrasound for assessing left ventricular function at rest and cardiac pulmonary exercise tests for assessing functional capacity during exercise.

Well, such a device may soon exis.

A word of caution. A blog, this blog in particular, isn’t a scientific report. It is, however, based on solid speculation and documentation about an exciting innovation, resting on data generated by fifth generation devices for measuring heart and lung function. It shows the power of informed and evolutionary innovation.

Friday, March 23, 2007

clinical innovations - Health Care Organizations: Select a Chief Innovation Officer

Within five years, I predict health care organizations of all sizes, shapes, and functions – health plans, hospitals, medical practices, support groups, consultants, supply chain vendors, health care associations, consumer groups -- will select someone within their organization to be their chief innovation officer.

The chief innovation officer will generate ideas, sift through them, pick winners, and lead organizations towards a future geared to productive change.

Right now only a handful of health care chief innovation officers exist – at the health plan giant, Humana; at Alegent Health, midsized hospital system in eastern Nebraska and western Iowa, and at Cadient Group, a health care marketing agency. No doubt other Chief Innovation Officers exist that have escaped my attention, but there are still too precious few Chief Innovation Officers.

Many health leaders are already serving as functional Chief Innovation Officers – CEOs and CIOs of hospitals and health plans, Chief Medical Officers, physician leaders, nurse executives, nurses and managers in physician offices. I don’t really care what title these persons bear, or whether they call themselves Chief Innovation Officers, Chief Information Officers, Chief Inspirational Officers, or Chief Instigation Officers, as long as they create, generate, foment, elicit, implement, filter, and test out new ideas.

The CIO’s chief functions are to stimulate, generate, and instigate ideas, principally from below – from managers, employees, people on clinical front lines, patients, staffs in medical offices, from consumers and the public at large. Workable new ideas generally do not not come from the top rungs of an organization, but from lower and bottom rungs, from service and interactive personnel on the front lines of care.

The CIOs other functions are to keep ideas flowing and to try them out, again and again, failing again and again, then starting out again. My favorite definition at the moment for “innovation” is this one, which I read in the March 20 New York Times.

Innovation is a constant process of trial and error. You need the willingness to fail all the time. You have to generate many ideas and then you have to work very hard only to discover they don’t work. And you keep doing that over and over until you find one that does work (Steve Lohr, “John W. Backus, 82, Fortran Developer Dies, March 20, New York Times).

John W. Backus assembled and led the I..B.M team that created Fortran, the widely used computer program language that opened the door in 1957 to modern computing. Perhaps this is my favorite quote because in the late 1960s, Russell Hobbie, a professor of physics at the University of Minnesota and I, used computer software, which Hobbie wrote in Fortran, to create a program that generated a differential diagnosis for abnormal laboratory results of some 600 tests that was used in 6 million laboratory reports.

What does a chief information officer do? Jonathan Lord, MD, chief innovation officer of Humana since 2002, says,

The CIO becomes the spiritual leader within the enterprise. His basic role to bring new ideas into health care and to find talented people who can handle ambiguity and who have passion for change – people who have comfort with new ideas, who can align beliefs, and who can co-create.

The CIO, in short, constantly co-generates idea, keeps the ideas flowing, and tests them out to see if they work or fail.

Harry Lukens, Chief Information Officer of Lehigh Valley Health Network in Allentown, Pennsylvania, has developed and chaired a group he calls the “Wild Idea Team.” It has a rotating membership of 18 to 25 people, at all levels of the organization. The team places no ideas off limits, and there is only one rule “no snickering.”

Health care needs more Harry Lukens.
Who take positively nothing for givens,
Who tolerate no gratuitous snide snickering,
Who forbid all internecine biased bickering,
Who believe out there lies some wild idea,
That may very well the key to the future be a.

Thursday, March 22, 2007

E-medicine - Data Mining, Predictive Modeling, and Innovation: Keys to U.S. Health Reform

Modified From my origina article in HealthLeaders News, June 27, 2006

Definition of Data Mining

The nontrivial extraction of implicit, previously unknown, and potentially useful information from data.

AI Magazine, Fall, 1992

Definition of Predictive Modeling

A process by which a clinical database is used to describe mathematically the likelihood of outcome events, given a set of variables on a new patient.

Liposcience, Inc, 2007

In “The Consequential Divide: Which Direction Healthcare?” (April 27, 2006), HealthLeaders contributor Preston Gee asserts a political divide exists between market-driven and single-payer advocates who seek to resolve cost, coverage and quality problems.

Either solution, the title implies, harbors profound consequences for health care stakeholders. It’s possible a powerful force embedded in American culture--our genius for innovation--will bridge the divide.

A New Solution

Experts point to five basic reform solutions that exist for the U.S.:

• A national universal system of coverage
• A consumer-driven, market-based system covering those able to pay
• State-by-state universal coverage, Massachusetts-style
• A national consumer-driven, market-based model with universal coverage through Federal Employee Health Benefits Plan or the Universal Health Voucher Plan, as proposed by the Mayo Clinic
• A modification of the current system, using managerially guided information technology systems to control supply costs, measure outcomes, reward performance, and control behavior of health plans, hospitals, doctors, and consumers.

I propose another approach incorporating all these solutions--systematic innovation by government and market-based organizations. This solution will take time. It overlaps government and private sectors, and it is not without doubters. George Lundberg, M.D., past editor of the Journal of The American Medical Association and now editor of Medscape’s MedGenJournal, observes, “Innovations tend to be limited and localized. For the masses, innovations would have to propagate like crazy.”

Comparisons Across The Pond

In Innovation and Entrepreneurship, Peter Drucker argues the U.S. entrepreneurial economy distinguishes us from Western Europe. Our current economic growth rate is 4 to 5 percent while Europe’s is 1 percent. The U.S. unemployment rate is half of Europe’s. To Drucker, such differences exist because U.S entrepreneurs are closer to customers while socialistic bureaucrats are isolated and remote from people.

Critics argue that Europe has universal coverage and better health statistics. True, but it’s at the cost of economic stagnation, long waits and limited access to medical technologies. One could persuasively argue U.S. innovations often are strictly technological in nature and have little to do with solving social problems ranging from the uninsured to high cost and poor quality. But I assert that these problems can and will be addressed in innovative ways in the political, data collection and deployment, information technology and healthcare organization arenas.

Major Innovations

Six major innovations, sometimes inspired by government, sometimes undertaken independently or in concert with the private sector, are driving health reform: data mining reform, consumer-driven care, pay-for-performance initiatives, national electronic infrastructure building, state-by-state reform experimentation, and “disruptive simplification” innovations at the practice management level. Data mining is the most important and sweeping innovation, because it gives us the tools to restructure and rebuild the existing system based on irrefutable and impersonal data.

According to Webopedia, the computer technology dictionary, data mining may be defined as “the class of database applications that look for hidden patterns in a group of data that can be used to predict future behavior. For example, data mining software can help retail companies find customers with common interests. The term is commonly misused to describe software that presents data in new ways. True data mining software doesn't just change the presentation, but actually discovers previously unknown relationships among the data.”

Four areas of data mining are transforming healthcare:

Medicare data mining

This form of data mining is not new, but it remains an inexhaustible innovation source because of its size. John Wennberg and Alan Gettlesohn first explored the Medicare Mine in 1973 when they published their classic findings on how medical care varied from one region of the country to the other. Ever since, Medicare data has been considered the sine qua non for studying and judging health costs and outcomes. Wennberg considers medical service variation across regions and academic center as “unwarranted.” The variation data, he concludes, does not correlate with better outcomes data. He has proven beyond statistical doubt that “more is not better.” Employers and health plans are aware Medicare data is a treasure trove for data miners wishing to improve quality and outcomes and to pay hospitals and doctors for performance, which is why the Business Round Table and others are pressuring the Bush administration to release all Medicare claims data.

Pharmaceutical data mining

I was present in Minneapolis in the 1970s at the creation of the UnitedHealthcare Group. Perhaps that is why I maintain that pharmaceutical data mining, outside of the billion- dollar leadership of William McGuire, M.D., is what made UnitedHealthcare what it is today. It isn’t generally recognized that 75 percent of United’s profits come from outside the traditional HMO business. In 2005, I spoke with Brian Gould, M.D., a former senior executive for United. “In early 1990, I moved to Minneapolis. I was in charge of United’s Specialty Operations Division--all the non-HMO businesses. These included a pioneering pharmaceutical benefit company, Diversified Pharmaceutical Services. In 1993, we sold DPM to Smith Kline Beecham for an astonishing price of $2.3 billion,” he said. Under the terms of agreement, United HealthCare agreed to provide Smith Kline Beecham “with access to medical data and outcomes analysis.” This meant access to United’s pharmaceutical data mining operation data. For example, if United had pharmaceutical claims data indicating who was taking insulin, Smith Kline could use that data to study a huge population of diabetics.

United has not abandoned pharmaceutical data mining. Its Ingenix division provides clinic research services, medical education services, and therapeutic outcomes and epidemiology research data to pharmaceutical companies, biotechnology companies and medical device manufacturers.

Printed Word Data Mining

Google is so powerful, it has become a verb. One no longer looks up information in medical libraries, one “googles” medical information. Google, I would argue, is turning the medical world upside-down. Medical journals, for example, are struggling to survive because of drops in advertising and readership. Moreover, Google has leveled the information playing field between doctors and patients. The late Tom Ferguson, M.D., a pioneer and prophet of the consumer-driven movement, put it this way in an interview I conducted with him in 1999: “Patient knowledge is different from physician knowledge. Depending on the area of specialization, a specialist might have to stay current on 30, 200 or 400 medical conditions. A general practitioner might have to keep up with 600. Patients only have to know about one disease--their own.”

Clinical, Practice Management and Practice Pattern Data Mining

In the 1970s and 1980s, in a clinical laboratory setting, Russell Hobbie, Ph.D., a physics professor at the University of Minnesota, and I used the Internet to develop two practical clinical applications using data available in physician’s offices--patient age and gender, physical measurements (height, weight, blood pressure), and laboratory data. From this universally available data, we developed two products--the Unified Presentation of Relevant Tests, a differential diagnosis report listing the top ten diagnostic possibilities, and the Health Quotient, a health status report based on height, weight, blood pressure, family or personal history of heart attack or stroke, and laboratory findings. UNIPORT was 80 percent accurate and was commercially successful; the HQ was acclaimed by its recipients and predicted imminent heart attacks with unexpected precision.

True Potential

The real potential of data mining lies in practice pattern grouping using existing data to define costs and consequences, and predictive modeling using broad clinical and financial databases to define the effect of current patient behavior, diagnoses, and interventions on future outcomes and costs.

Practice pattern grouping often goes by the name of episode grouping. As government and private healthcare organizations seek to deliver top-quality care more cost-effectively, episode grouping has come into vogue. By clustering costs around a clinical episode--everything from doctors involved, to diagnoses, to medications, to interventions, to hospitalization, to rehabilitations, to nursing home care, to outcomes-- you can more precisely analyze total outcomes and costs. You can also more accurately—and fairly—assess physician performance.

Much of the total cost, for example, of hospitalizations resides in the hospital’s costs. Hospital charges make up about 80 percent of physician costs in the hospital setting. The hospital charges may be beyond the doctor’s control. On the other hand, drugs doctors prescribe or interventions they choose are not. It has been found that total episode costs may vary by factors of as much as 20 to one. In these instances, and even with smaller variations, systematic or structural reforms are in order. True reform lies in rationalizing, not rationing, care.

Predictive Modeling

Predictive modeling requires a more sophisticated mathematical approach and artificial intelligence deployment. One of the pioneers in this field is David Eddy, M.D., Ph.D., who, over the last 10 years at Kaiser Permanente, has developed a predictive model called the Archimedes Model. This model provides a mathematically based lever that moves and manipulates vast amounts of data in a way that simulates reality. It improves and speeds healthcare decision-making at decision points along the healthcare spectrum. Archimedes, funded by Kaiser, has been 10 years in the making. It uses mathematical simulation to create a visual world to help healthcare organizations make critical and administrative decisions. The model has been repeatedly tested and validated to answer complex real-world decisions. In the words of a Kaiser publicist, “The Archimedes model has virtual people who get virtual diseases, go to virtual doctors, get virtual tests, receive virtual treatment, and have virtual outcomes.” Using Kaiser’s eight million-member database, Archimedes played a role in the Vioxx recall, and it is currently being used as a tool to conduct virtual clinical trials by major pharmaceutical companies.

Another company pursuing goals similar to Archimedes is MedAI (short for Medical Artificial Intelligence) in Orlando, Fla. MedAI’s outcomes measurement application, Pin Point Quality, enables users to easily identify specific steps to monitor and improve clinical outcomes while reducing healthcare costs. Clients can integrate data from clinical and financial legacy systems. This allows clients to undertake quality initiatives. Medical directors, administrative directors and other members of the organization can create reports of quality indicators, which they can then use to drive practice changes in their organization.

In formulating the argument that America innovation in general and innovation in the handling of data in particular will change the world, I have only touched briefly on such innovative and powerful movements as consumer-driven care, pay-for-performance, the building of a national electronic infrastructure, the political innovation in Massachusetts, or “disruptive innovations” that are simpler, less costly, and more convenient to use. These are all terribly important, and their full potentials will, no doubt, require data-based innovations.