Executive Advisory Program

1984 is Here for Healthcare, Hallelulah!

Back in the day, I once had a boss that was fairly savvy, and a senior exec at a major insurer (all of you long-time followers can figure out who/where).  The year was 1984 and the topic was healthcare reform.  He said "There's too many vested interests, and too many people making money, for much to change substantively in the healthcare system".

26 years later I am much grayer, older, and (unfortunately) unhealthier.  And most of my career has, in one way or another, held his maxim to be true.

I remembered that quote when Scott Brown was elected in Massachusetts, and it looked like the end of yet another run at healthcare reform.  I wasn't alone.  Angela Braly, the CEO of Wellpoint,  had an epic interview in the Wall Street Journal that said effectively the same thing.  I agreed in some ways with  Ms. Braly - a wasted opportunity, an ineffective bill at addressing root causes of healthcare spending growth, a chance that reform would make things worse and not better.

BUT THEN IT HAPPENED.

Putting aside all the politics, the arguments about BIG government, the tax and balance sheet impacts, and even the philosophical underpinnings of what this means to be "An American" (cowboy boots and all) - I do believe that this moment in time reflects a maturation of our country.

What was really  intriguing to me about Braly's comments was not the analysis of the healthcare bill and it's good or bad points, but her view about the role of insurers. Insurers have gone through this cycle as healthcare financiers, healthcare deliverers (the 90s had much discussion about building delivery systems), and now seem to be settling into the role of information brokers.

This is huge, and a very important insight by Ms. Braly.  It's something we have been talking about at Burton Group - the primacy of information management,  under the nom-de-plumes of "Business Intelligence" or "Business Process Management".  It's a business model that will have huge impacts on healthcare and healthcare IT.  We'll see significant growth in the whole healthcare information system - from data capture, to storage, to analysis.  Google and Microsoft see it, and it may be the only way left for healthcare insurers to compete.

Kudos to Angela Braly on recognizing it. Sympathies to her as well for such a poor forecast on the future of the healthcare bill. Stay away from the horse track.

This year, holy week and passover coincide.  For Christians, its about death and re-birth.  For Jews, the promise of redemption. The ramp-up to this week saw all this happen with healthcare reform.  Goodbye, 1984.

Cloud-fuscation

Posted by: Jack Santos

Part of the Gartner/Burton integration plan calls for, of course, integration of benefit plans.  I have some particular insight here, since I have been on both sides of that equation – in health insurance IT, and as a health care provider CIO. 

Insurers have always been on the leading edge of technology usage – and that continues to be the case. There is extensive use of websites, online modeling, customer based data entry, and self help.  It’s cool stuff.

But it’s also an example of a nascent problem with “cloud computing” – or even its red-headed step child: e-business. 

As businesses have found that an internet-based delivery model solves many issues (and reduces many costs) they have gone at it with a vengeance. So has government – health plans are becoming increasingly complex (HSAs, HFSAs, CDHP are all in the alphabet soup), because a side effect of increasing automation is that it is (ostensibly) easier to develop more complex plans, and easier to deliver them.  Hence, like water flowing into an empty glass, the level of complexity rises.

The role of IT leaders is changing – no longer are we just the advocate of automation, we must be the advocate of appropriate and judicious automation – whether it’s through participation in business strategy, or government regulatory frameworks.  An excellent primer on this is “The Laws of Disruption – Harnessing the New Forces That Govern Life and Business in The Digital Age” by Larry Downes.

This issue is not unlike a situation I found myself in a few years ago.  After months of bake-offs, evaluations, vendor grilling, RFIs, RFPs, etc, we were about to make a major software decision, and were reviewing vendor contract terms (it was a 15-20MM dollar purchase).  Of course, the contract was internet accessible, PDF format;  And it was littered with hyperlinks to terms on web pages, references to commitments on web pages, and detailed product features on web pages.

I wouldn't sign it; they were reluctant to change it, and it almost cost the deal.

Besides the complexity of referencing material outside of the signed document, there was the issue of audit – clearly those web pages change frequently, almost at whim – with no clear audit trail of who/when/where/why.  God forbid we should get into an argument at a later date (inevitable) and both parties look at the terms – just to find they were written on beach sand that had been scoured by hundreds of successive tides of changes…..In the end, they dutifully printed out all of the referenced web pages, we reviewed them, and explicitly included them in the contract.

I submit this is an example of yet another potential unintended consequence of cloud computing; we are attracted by the dynamic and elastic aspects of cloud, but those same features can be detriments to a long term, sustainable business model. 

A potential way to deal with this may come out of design thinking and hybrid thinking approaches.  Gartner research is exploring that genre of ways to think about IT solutions, and the impact on business strategy…

When I had 20 different websites open from 5 different companies, and multiple time-sensitive modeling and data capture pages in process, it occurred to me that the benefits enrollment process is approaching lunacy-- not any one business’ fault, just a zeitgeist. I am not sure whether health care reform (if it ever happens) will worsen or improve this situation.  But issues around appropriate automation, user interface design, and silo integration are at the heart of what should be on an IT leader’s agenda for the coming years….and cloud computing will only add fuel to the fire…

Now if I can only get Fidelity to stop insisting that I only rely on web-based statements and alerts….

The Golden Age of Computing

Posted by: Jack Santos

Occasionally I gain insight into where things are going such that it really excites me about the direction of our profession, and of the human race.  That happened today, with a briefing from IBM research.

We live in a world where heart transplants, ear implants, hip replacements are all routine.  Often the recipient is better for it coming out of the procedure than they were going in.

IBM didn’t say this, but what I gleamed was that within my children’s lifetime, we may not only be looking at our traditional organic transplants, but we’ll achieve stand alone compute capacities that will enable us to mimic the human brain.  Think brain replacements.  By 2020 we may see the mechanics in place, so sometime beyond that could see that kind of breakthrough.  Compute capacity today is already equivalent to cat-brain capacity (the IBM Dawn effort at Lawrence Livermore Labs).

Head trauma, Alzheimer's disease, memory enhancement, brain augmentation – all are areas that could see significant research benefit.  On a separate but related track are efforts like Google’s where access to information ubiquitously will only make this vision even more likely (or Frankenstein-ingly threatening).  I sometimes feel like an extension of the internet: answers to obscure questions come to me within 10 seconds by speakingto my iPhone.  The result is that I already mentally compartmentalize what I need to remember, and what I can conveniently forget, because of the ease of this access.  I am, as a biological entity, already being enhanced by compute technology – and the trend is accelerating.

2020…the new 2012, at least for IT. But not the end of the world, the beginning of a new one…

Of Garages and Hospitals: The Mechanics of High Tech Healthcare

Posted by: Jack Santos

Those of you that know me or my background know of my healthcare IT pedigree – on both the insurance and the provider side.   Keep that in mind when reading this post, because  my comments can be easily misconstrued. 

One of the key concerns for healthcare IT advocates (and detractors) is the  automation of healthcare; kind of a care assembly line.  This has certainly been a concern of some watchers of the debate going on at Capitol Hill.

This concern manifests itself with alerts and reminders in an Electronic Medical Record system, leading to complacency on the part of the clinician.   I recently saw a similar phenomena happen when I took in my brand new 2009 car to the dealer for a perceived warranty issue.

Mechanics courses now focus heavily of use of computer based diagnostic testequipment.  By connecting to the car’s on-board computer (OBC) system, a mechanic can measure and detect all sorts of things – alerts on component failures, out of spec operation, even speed and acceleration statistics (which would be a boon for auto insurers and rate determination – but that is for another post).

In my case, my cruise control on my new car was working erratically – sometimes over 30 MPH, sometimes under 40, sometimes never.  After three trips to the shop, and numerous on-line lookups by mechanics for similar service recalls or problem reports (each time downloading codes from the OBC and diligently following alerts and repair protocols) they determined that the problem was an obscure part that rarely fails, especially in so new a car: an electronic brake light switch.  It would take a month to get a new one from the factory.

What the mechanics failed to do in this entire diagnostic process was to actually LOOK at the patient (in this case, my car).  Even a rudimentary look would have revealed that an after-market hitch harness for brake lights had been installed (by yours truly).  The manufacturer of the hitch harness had incorrectly listed this make and model as compatible.  The electronics in the harness (which was supposed to just extend the brake light signal to a trailer) interfered with multiple things in the car – including the cruise control.  I removed the harness – and problem solved.

This automotive story is a perfect example of what I would call process automation complacency.  Complacency that would be the result of relying totally on pretty (although busy) computer interfaces (like the one above), automated alerts, reminders, computer based knowledge bases – at the expense of rudimentary human-based diagnostics, or even common sense.

In this automotive case, the results were just annoying; in the case of back office processes, it could be an impact to the bottom line, or even financial reporting.  But in healthcare -  it could be a life lost.

Should that derail the Electronic Medical Record juggernaut?  I think not.  But it should make computer professionals, and healthcare executives, sensitive to  all the other aspects of a healthcare delivery system – including training,  and the cultural/sociological implications.  Cars can be replaced – human lives cannot.

Readiness to hand

I've been thinking about Joe Bugajski's recent blog post about his health ordeal and resulting skepticism about electronic medical records. OK, skepticism is perhaps a bit mild compared to what Joe actually feels.

Joe had a life-threatening health emergency in early 2009 that was exacerbated by innacuracies and user experience problems in the electronic medical records system. He calls out weak data modeling as the culprit preventing effective insight into his medical history, medications, and courses of action.

As I read deeper into Joe's personal blog, some other things emerged that I want to call attention to. Health care culture and style of work, especially in fast-paced emergency settings, may resist the intrusion of technology beyond that which attaches to the patient's body. To ask a doctor or nurse to divert their attention to data entry or retrieval takes them away from their primary goal, even though that data may contribute to the overall care of the patient. In effect, the technology becomes a distracting third-party to the provider-patient relationship. It is not a passive technology, and as a result may actually increase the risk of medical error.

To be effective, medical records technology must be passive and comprehensive. It must become transparent through its use, so that the provider-patient relationship is strengthened, not weakened. As Joe suggests, data modeling is an essential component of ensuring that the correct data is surfaced at the correct time to the correct device/person. The data model is a logical representation of the patient drawn from various sources— some historical and some real-time. Some data is more critical than others, and that criticality can shift in the midst of care. It is not a replacement for human insight. Automation of patient data will not improve care on its own. Automation of correctly modeled data should facilitate and accelerate human insight.

Electronic medical record technology should fit the various ways that medical professionals work. To the extent possible, EMR approaches should be woven into the ergonomics of care. But at this early stage, EMR processes are bolted on to hospital procedures. Perhaps the early demand for EMR is driven by liability protection vs. improved care. The paradox is that unless EMR entry and retrieval is integrated into overall work practice, risk and liability increases.

The German philosopher Martin Heidegger wrote about "throwness", "breakdown", and "readiness-to-hand", and they apply in this and many other human computer interface (HCI) scenarios.

Throwness is the ability to react intuitively in highly fluid situations.Throwness is the result of learning and assimilating actions so that they can be performed without active analysis or thought. When it comes to golf, for example, Tiger Woods exhibits throwness.

Breakdown occurs when intuition is interrupted, and the objects present in the scenario stop functioning as a cohesive set. Breakdown occurs, for example, when your car blows a tire at high speed, and your attention is suddenly drawn to the control of the car. In effect, those actions that were suppressed into your mid-consciousness come to the fore. Breakdown occurs in HCI when your intuitive actions are distracted by system issues (like crashing programs, annoying data entry).

Readiness-to-hand occurs when a tool perfectly matches its function. You see a nail, you reach for a hammer. There is no analysis necessary. The act of hammering a nail is not intruded upon.

It is difficult to design sophisticated tools that allow for human "throwness", avoid breakdown (or handle it gracefully), and reach the stage of readiness-to-hand. This is especially true in a highly human-dependent work environment that moves at an accelerated and interrupt-driven pace. Unless the technology you place into that environment is "ready-to-hand", it will inhibit effective work rather than supporting it. I'm afraid that's what happened to Joe.

So, healthcare will not be improved with EMR alone. Good data modeling, coupled with significant user experience design will work together to make humans more effective and healthier, too.

Disaster Recovery and Business Continuity – not just for geeks anymore

Posted by: Jack Santos

I live in a remote Burton Group outpost in the wilds of New Hampshire.  As you may have heard, about 2 weeks ago we had an ice storm that took out electrical power to about a third of the state, and has been characterized as the “most devastating natural disaster to hit New Hampshire in recent history”, according to the power company (350,000 outages in the state of 1.3M people).

As we approach Christmas, utilities are working feverishly to get the last homes on-line; these are people that have endured two major snow storms without electricity, EACH dumping up to 12 inches of the fluffy stuff.  In New Hampshire, we are a hardy bunch.  I personally spent 2 days siphoning ice water from the swimming pool as a partial water supply, and huddling around the fireplace. (photo: Rockingham News)

As I sat around my battery backup (I’ve avoided buying a generator, am considering solar and wind) and used 3G to keep plugged into the world, it occurred to me how IT is fundamentally changing how companies respond to disasters.  Even though I have been heavily involved in Amateur Radio disaster preparedness for part of my life, this first became obvious about 15 years ago when I took on responsibility for medical facilities.  Up to that time I had made the transition (over 10 years) from worrying solely about data center backup, to worrying about data center and office recoveries, then worrying about business processes, and how they are done, in a time of outages.  That’s when IT recognized that Disaster Recovery and Business Continuity are not synonymous.

During my tenure at Kaiser Permanente and Catholic Medical Center, I changed my mindset even more.  I can even remember the day - a simulated disaster drill.  You see, in hospitals and medical centers, disaster drills are done routinely.  No – this isn’t simulating a data center meltdown, or a facility outage.  This is setting up a tent in a parking lot to triage patients from a simulated bomb blast or plane crash, and then complicating it with communications, power, and computer outages.
It dawned on me that day in 1996 that DR/BC is transitioning.  And it dawns on me this year how that continuing transition reflects the transition  of IT as a whole. (LA's Cedars-Sinai Disaster Drill)

I tried to reflect on that in the recent Burton Group report: “Is IT losing control of users or are users gaining control of IT”.  The basic premise is that IT is integrated with the business,  that business people are (or should be) much more involved in IT decision-making than they have been in the past, and that IT people shouldn't feel threatened, but focused on business objectives.

How does that relate to the ice storm?  It should be obvious that the work-flow, internal communication, job status reporting, equipment ordering and provisioning are major internal IT systems that must keep operating during a storm, not only for power companies, but for any company caught in the midst of a major meltdown (or ice-up).

But even more amazing is how IT can contribute to the externalization of communication, and fundamental business processes, with customers; I saw in this disaster the seeds of how technology is integrated in a company’s disaster response:  constantly updated web pages, twitter updates of power restoration by power company workers, email, RSS status update feeds, multi-mode customer input vehicles (cell phone, email, SMS) for power outage reports.

That’s the nexus of consumer technology meets IT, and how IT can play a leadership role in not only making sure those services stay up during an emergency or a disaster, but that they are also thought of as part of the business plan for operating during a disaster.  IT means closely working with the business, and being open to consumer-based ideas coming from the business.

Fortunately, in a hospital setting you are required to have a disaster planning officer – which is the focal point for all planning and dry-runs of major man-made and natural disasters.  Working closely with that person is critical.  Most commercial establishments don’t have that (necessarily), or lump that into security, or facilities, and give it short shrift.

Businesses would do well to take a lesson from these outages – especially on how to respond to customers, and customer communications.  This particular 2 week outage is already calling for heads to roll (fairly or unfairly), and government investigations – not so much as why there was an outage and whether the power companies responded adequately enough - but more around communication to municipalities and customers and how that can be improved.

Disaster Recovery and Business Continuity – not just for geeks anymore.

Happy Holidays, everyone.

Pharma IT and the Future

Posted by: Jack Santos

Those of you that have followed my blog entries here know that I have a fairly unusual IT background that spans different industries. The majority of my background is in financial services/health care (payer and provider/hospital). That gives me a unique outside looking in perspective on yet another big industry: Pharmaceuticals.

I recently had the chance to review some industry research on the challenges facing Pharma, and have come to the following conclusions about implications to IT:

Pharma's challenge is that R&D costs have doubled, while new drug approvals have halved (over 5 years). That can't go on. They are going to have to use IT to:

1. Reduce costs

• For both back office costs through efficient HR/sales/finance apps,
• and core R&D and trial costs through better workflow/management and (longer term) virtualized trials with biosimulation and predictive analysis.This is Pharma's version of Business Intelligence on the commercial side.
• Minimizing the infrastructure costs of massive data management through use of tools like virtualization (processor and storage) and new Database options that are coming to market.
• Establishing an infrastructure that easily plugs-in /plugs-out third party R&D/Lab/Trial software tools to achieve a level of integration for researchers, and reduced costs/time for IT support.

2. Enable Better, Effective Research

• The successful companies will get very good at managing R&D with partnerships on the payer and provider side

• Better outcomes measurement, and improvements in measurable efficacy

• Increased computer/data linkages to payer/provider partners
• Increased management of payer/provider relationships (much like Customer Relationship Management software)

There will be significantly increased regulation and compliance, driving the need for template-based and workflow driven processes to ease the time and cost associated with increases.

A lot of this will depend on Pharma IT's ability to recognize new trends (like the kind our research focused on in NTS, DCS, or DMS), and plan for those changes. It also requires more of an "outward" facing IT assessment that sees the need for automated collaboration with payers/providers and the enabling technologies (cloud computing may be one) that could make that happen.

Pharma has some interesting challenges ahead, indeed, but a lot of lessons that can be learned from other industries.