An Economist’s End-of-Life Wishes: One-Hoss Shay Depreciation

Aging in place and end-of-life care were among the hot topics at the Partners Connected Health Symposium last week, which reminded me of comments I have made in the past regarding the ideal “one-hoss shay” method of living well for a full lifetime until a quick sudden death occurs.

Let me explain. Early in my career, I worked at the Urban Institute for an economist (Charles Hulten)  who specializes in depreciation theory and productivity analysis. We held a conference and published a book with the incredibly sexy title, “Depreciation, Inflation & the Taxation of Income from Capital”. Sounds like a pager-turner, right?

Well, one of the fun things I did to prepare for the conference was to go to the rare books section of the Library of Congress to find a copy of Oliver Wendell Holmes’ poem, The Deacon’s Masterpiece, or the Wonderful One-Hoss Shay: A Logical Story. I wanted to use graphics from the original book for the flyers we printed for the conference. (Note, shay is a anglicized word for  the French word ‘chaise’, which refers to a carriage; hoss is simply the way some of us in New England pronounce the word “horse”!).

The field of economics uses the term “one-hoss shay” depreciation to describe assets that retain their useful value until they rapidly fail (like a lightbulb).  

In the poem, the deacon constructs his one-hoss shay in such a balanced and logical way so that no part represents a point of weakness:

For the wheels were just as strong as the thills,
And the floor was just as strong as the sills,
And the panels just as strong as the floor,
And the whipple-tree neither less nor more,
And the back crossbar as strong as the fore,
And spring and axle and hub encore.

Nonetheless, exactly 100 years after it was built, the carriage succumbs to the decay of old life:

And yet, as a whole, it is past a doubt
In another hour it will be worn out!

First a shiver, and then a thrill,
Then something decidedly like a spill, —
And the parson was sitting upon a rock,
At half past nine by the meet’n-house clock, —
Just the hour of the Earthquake shock!
What do you think the parson found,
When he got up and stared around?
The poor old chaise in a heap or mound,
As if it had been to the mill and ground!
You see, of course, if you’re not a dunce,
How it went to pieces all at once, —
All at once, and nothing first, —
Just as bubbles do when they burst.

End of the wonderful one-hoss shay.
Logic is logic. That’s all I say.

As you might guess, my interpretation of the poem lends itself to anthropomorphizing the shay to the human body (remember Holmes was a physician and a medical reformer:  https://en.wikipedia.org/wiki/Oliver_Wendell_Holmes,_Sr.#Medical_reformer.2C_marriage_and_family)[1]. In brief, in my view, the ideal scenario for end-of-life is a quick catastrophic end that punctuates a long healthy life. We can’t all avoid disease, but we can follow the deacon’s playbook and attempt to keep our bodies in balance and as healthy as possible as long as possible.

Would you say our current healthcare system is optimized for one-hoss shay depreciation, which requires an emphasis on preventive maintenance so that our bodies don’t “break down” but rather “wear out”? I know my answer to that question.  The more important question is: how do we change the current system that resembles a repair shop more than it does a health maintenance system?

Just the fact that we’re addressing end-of-life issues as major themes of healthcare conferences like the Connected Health Symposium and the fact that end-of-life issues are being raised in mainstream media indicate that we’re making progress.

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I recommend this YouTube reading of The Deacon’s Masterpiece by Eddie Arnold (some of you may remember him as Oliver Wendell Douglas from Green Acres!): https://www.youtube.com/watch?v=wiOHhhwnK6k

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[1] Reading this part of Holmes’ biography led to me check for references  to Holmes in Thomas Goetz’ new book, The Remedy, Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis, which I purchased at the Connected Health Summit. Indeed there are references to Holmes (not just Sherlock) in the book and there are obvious connections between the two Holmeses. 

Health Data Management Top 16 Health IT Experts List

Health Data Management Magazine is an obvious go-to source for me, given my focus on developments related to the sources and uses of health data.  

It’s gratifying to see that the feeling is mutual. HDM Magazine recently published a list of 16 Experts on Twitter Who are Leading the Discussion in Health IT and included me among some highly respected peers.

Any curated list is going to leave out some equally good candidates. Every time a list comes out, people who aren’t included tend to call out bias in the selection process. There’s always bias. But, as a publication that is well-versed in editorial curation, HDM Magazine does an excellent job of selecting a core group that is consistent in their focus on health IT and data-driven developments in healthcare and are known for providing a good deal of context around the issues. Better yet, the group includes a range of perspectives from within provider organizations, health IT vendors, patient advocates, government agencies, analysts, start-ups and research foundations. Despite the different perspectives, this group includes people who demonstrate a genuine interest in improving our current healthcare industry (I would say “healthcare system”, but that raises too many thoughts about lack of systems thinking in healthcare).

I don’t know if HDM Magazine made a conscious effort to include an equal number of women and men, but if they did, they exceeded that goal by naming nine women and seven men. In today’s world, that still merits a special mention and a “thank you” from the #HITChicks community!

Here’s the complete list of Twitter handles:

@EricTopol

@SeattleMamaDoc

@ePatientDave

@Farzad_MD

@SusannahFox

@DrVal

@Cascadia

@Nxtstop1

@MandiBPro

@janicemccallum

@john_chilmark

@KBDeSalvo

@DrLeslieSaxon

@StephenJDowns

@kmmore

@deansittig

The list includes some people who have been part of my Twitter community from the beginning (e.g., @ePatientDave @Cascadia and @SusannahFox) and some newer colleagues and friends and a couple of people I should obviously add to my list. 

Note, HDM Magazine created a similar list several years ago of top health IT social media people to follow and John Poikonen (@poikonen)  created a public Twitter list to make it easy for anyone to follow all the people on the list. That list remains one of my favorite lists to scan each morning. Note, John has added a few names to his list, as is his prerogative. In that same vein, I’ve just created a public list with all 16 of the health IT experts that HDM Magazine included on their list and have made two additions: @HDMMagazine and @poikonen! Here’s the link to the public list:   

https://twitter.com/janicemccallum/lists/hdmhealthitlist

Mom-memorials from #IHeartHIT Session at HIMSS15

Lindy Stotsky, known to many of you by her Twitter name @EMRAnswers, gave a compelling and compassionate account at HIMSS15 of how the lack of access to patient records — by clinicians, patients, and especially family members/caregivers— failed her mother during her stay in a long-term care facility. Her story, appended below, resonated with the audience and led several other people to describe how experiences trying to navigate the healthcare system without full access to information from health records spurred them to become involved in health IT.

I followed Linda with a story of how my mother became interested in examining the data in her health record only after I prodded her primary care practice to provide access, once I realized that they had implemented a patient portal.

It was notable that most of the personal stories from the audience that followed Linda & my brief talks at the #IHeartHIT session related to caring for our Moms. I want to thank Linda for sharing her story here on the Health Content Advisors site.

I Was My Mother’s “Scrap of Paper”

I’ve worked in healthcare over 25 years:  In administration through hospital credentialing and procurement, as a practice administrator shuffling through paper charts, missing codes, and reimbursement in an era of managed care.  It was during this time that my Mother became ill with CLL (Chronic Lymphocytic Leukemia), and COPD (Chronic Obstructive Pulmonary Disorder). My Mother was a staunch believer in Health CARE. She grew up believing that physicians were healers- and that nursing facilities took care of the elderly. Her decision to reside in such a facility began our descent into a world I could not have imagined.

I looked, as most caregivers do, at the inside of the building, the floors, the paint and the aesthetics. We are preoccupied, vulnerable and first impressions are everything. I judged the worthiness of the facility by its locale, the staff and our welcome.  I took for granted that “Nurses” were RN’s, having an MD as Chief of Staff meant he was there every day, and daily living meant more than struggling to survive. I didn’t know about physician track records, medical malpractice and negligence. All blue skies and daisies, until my Mom became a resident. That started our fragile dance between long-term care (LTC), emergency departments (ED), hospital, provider, back to LTC.

Thus began my advocacy. Not just for MY Mom. I was vigilant about everyone’s Mom— policing halls, looking into rooms, and answering cries for help.  I watched my Mother change from a vibrant, confident superhero to a terrified, confused and helpless patient. I took her to providers who placed her on medication, only to bring her back to a facility where medications were routinely discontinued because of cost.

I was “on call” 24/7. My Mom became my mission. My 3 year old knew where all the toys were kept in the ED, as we were frequent fliers.  “AMA” meant no ambulance was ever called. I loaded her, her wheelchair, her O2 tank, and my son into the car, and as I was running out, I grabbed a piece of notebook paper with her medications scribbled on it. This was her medical record. And I was the keeper of the key information.

My Mother passed away after three years of suffering, much of which was preventable. Not only was there a lack of communication, a culture of caring had been replaced by one of cost. Human lives took a back seat to ROI. Instead of treating aging elders with the respect and dignity they deserved after years of giving, nursing homes were nothing more than “death beds” waiting to empty. I was so engrossed in the day to day challenges, that I didn’t have time to stop and think about the larger picture of what was wrong. 

15 years later I am sorry to say that things have not changed much. My daughter recently had Thyroid Cancer. She was eager to use the patient portal to coordinate her labs, multiple tests, from all providers.  It was not that easy.  Information gaps were everywhere; care coordination was still back in the year 2000.  We need patient access. But it’s more than that. We need actionable information. It’s been nearly five years since the enactment of the ACA and little has been done to promote shared decision making. The recent proposed rule change in the Meaningful Use Stage 2 measure related to patient access and downloading of their information[1] will reduce the  threshold for Measure 2 from 5% to “at least 1 patient”  for eligible providers (EP). This change HALTS progress. WE CAN DO BETTER. My daughter is working hard to be a partner in her care, yet she has a toddler, and she’s tired, and sometimes it’s easier to give up rather than continue asking.

 Linda, Regina Holliday and me at HIMSS15

 Please help us win this. Stand up and ask —-demand electronic access to your patient record.  We should not have to carry around a tattered scrap of paper with medical information on it. Join members of The Walking Gallery[2] of Healthcare as we tell HHS, CMS, Politicians and Advocates that PATIENT LIVES MATTER.

My name is Linda Stotsky, and I share my story as a patient, a caregiver, a Mom, a daughter and a Health IT Product Manager. I am currently the Director of Business Development at LogicNets.

 I can be reached at Linda.Stotsky@gmail.com or on Twitter via @EMRAnswers

[1] http://e-patients.net/archives/2015/05/add-your-voice-meaningful-use-regulations-musnt-leave-patient-engagement-in-the-dust.html

[2] For information on TheWalking Gallery, see http://reginaholliday.blogspot.com/2011/04/walking-gallery.html.

Data Was Big at HIMSS15

Data Was Big at HIMSS15

Since I attended my first HIMSS in 2010, my consistent theme has centered on the fact that implementing EHRs with some standard functionality was a necessary precursor to achieving the core goals associated with improving quality and increasing the value of the healthcare we provide to individuals and groups. Having the ability to track and analyze outcomes in a systematic fashion benefits medical researchers, payers, patients, and policy makers (Pharma and device companies, too), not just providers.

HIMSS15 confirmed that the spotlight is now on data—and what can be done with digital data. In other words, we’ve moved on from the era of adopting EHRs to the era of leveraging the data collection and reporting capabilities of EHRs. To someone who has been a champion of “meaningful use” of EHR data through the rough times of less-than-perfect EHR platforms, I feel as though the HIMSS universe is finally reaching the stage where the benefits of putting outcomes data to work via software solutions are apparent.  

Marc Andreessen said that “software is eating the world”, but from my perspective software isn’t of any use without the data to fuel the software engine.[1]

Granted, we haven’t entirely said goodbye to issues related to basic EHR architecture, usability, and interoperability, but the spotlight has shifted to what can be done when the data generated by EHRs and other sources. Note, it goes without saying that careful data management is required throughout the entire process of generating, analyzing, integrating, sharing and reporting data.

In a follow-on post, I’ll dive more deeply into some of the clinical decision support solutions I saw at HIMSS15. For this post, I’ll stay at 35,000 feet and review the HIMSS15 experience relative to my expectations.

A couple of months prior to HIMSS15, I was asked by the HIMSS Social Media organizers what top trends I expected to see at HIMSS15. I narrowed it down to three topics:

1. More advanced uses of population health data.
2. Consolidation in the health IT segment led by enterprise software vendors.
3. Evidence of 2015’s becoming the “The Year of Patient Decision Tools”.

I’d say I scored a 2.5 out of 3, but let me explain in case you don’t see things through my lens.

On the first trend, I don’t think anyone would argue against the point that population health applications and analytics were at the top of the list of buzzwords at HIMSS15.

Regarding the continued relevance of the Meaningful Use program, I’ve argued in the past that we’ll know that we’ve made progress when we no longer need external regulations to drive optimal design and use of health IT systems. At the current time, healthcare providers are still largely driven by external regulations, except we’re moving from ONC-driven EHR adoption incentives to CMS reimbursement/payment-driven policies. Long-term changes in payment/reimbursement and delivery models will have a stronger impact on IT priorities of providers than a short-term incentive program like the Meaningful Use program.

On number 2, the consolidation theme, this is what I wrote prior to HIMSS15:

Just about everyone expects consolidation among the fragmented EHR vendor segment; but I predict that we’ll start to see some EHR vendors acquired by large multi-industry enterprise resource planning (ERP) vendors, such as SAP or Oracle. The large vendors have experience integrating multiple systems and already have some experience in healthcare with financial and talent management software systems. It doesn’t take a big stretch of the imagination to envision further integration with clinical systems, especially in light of new payment models where financial performance is a function of clinical performance.

It’s a shame I didn’t include IBM in my list of large multi-industry enterprise vendors, since one of the biggest announcements was the acquisition of Explorys and Phytel by IBM for its Watson Health unit. [2]

Although Watson Health isn’t an ERP solution, it is part of a large corporation that provides multiple solutions to provider organizations. Furthermore, IBM is more entrenched in the business side of the spectrum and building up Watson Health represents an investment on the clinical side of the spectrum. My overarching point is that new reimbursement models are driving the need to close the divide between admin systems and clinical systems. New reimbursement models tie financial outcomes to clinical outcomes, so admin and business intelligence systems need to integrate clinical outcomes data.

On point 3, with my optimist hat on, I predicted that HIMSS15 would highlight patient decision tools, not only decision tools designed for clinicians. I did see some impressive communications and decision tools for patients, including GetWell:) Network and Tonic, which has partnered with Elsevier to market its patient engagement solution. There were other patient engagement & decision tool vendors at HIMSS15, and this topic merits more attention. For now, I’ll stick with my prediction that in 2015 we’ll see a lot of activity in the patient decision tool space and I will provide more indepth coverage later.

Finally, I’d like to thank HIMSS for including me in the Social Media Ambassador program this year. It was terrific to be grouped with the elite digerati in health IT and healthcare. This is a forward-thinking group that generously shares their insights via social media.

I’ll wrap up with a few photo highlights from my HIMSS15 experience. 

The awesome Social Media Ambassador group for HIMSS15. Nearly all long-time health IT social media friends, along with a couple of new connections for me.

Meetup of #TheWalkingGallery members at the #IHeartHIT session on Monday, April 13, 2015. 

 

Last, but not least, the HIMSS experience always extends into the evening. Here’s one of my favorite pictures, a group selfie taken by @DrNic1 at John Lynn’s #HITMC meetup at Gino’s East on Tuesday, April 14, 2015, with @DrNic1, me, @OchoTex and @askJoyRios, photo-bombed by @DocWeighsIn and @SarahBennight:

Stay tuned for additional posts on HIMSS15 that will cover developments in Clinical Decision Support. 

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[1] Marc Andreessen, Wall St. Journal, August 20, 2011:http://www.wsj.com/articles/SB10001424053111903480904576512250915629460, accessed April 23, 2015.

[2] http://www.healthcareitnews.com/news/ibms-big-buy, accessed April 23, 2015.

Update on Thursday, April 23, 2015 at 3:55PM by Janice McCallum

I realize I should have included a link to the HIMSS site. I shouldn’t assume everyone knows what the acronym stands for — even though the reach & reputation of the HIMSS brand extends far enough to attract over 43,000 people to the annual conference! Here you go: HIMSS.org and HIMSSConference.org.

Surplus of Blame, Shortage of Trust: Healthcare, Heal Thyself!

Introduction

In 2012, following the HIMSS12 conference, I wrote about the importance of trust in healthcare exchange markets. Here’s an excerpt from my blog article 3 years ago:

The importance of building and maintaining trust among entities that are collaborating or exchanging goods & services is paramount. Without trust, markets where imperfect or asymmetrical information exists won’t operate efficiently. Whether we like it or not, “imperfect” and “asymmetrical” define the current mechanisms used to exchange personal health information.

So, how far have we come in three years? This guest post by Frank Ingari, President & CEO of Navinet, Inc., indicates that we still have a long way to go to develop adequate trust between payers & providers in order to achieve the level of risk-sharing and collaboration needed for new models of healthcare delivery.

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Surplus of Blame, Shortage of Trust: Healthcare, Heal Thyself!

After putting in their 10,000 steps a day at HIMSS15, anyone can tell you how much blame there is to go around in the complex dysfunction of U.S. healthcare. Rapturous vendor claims aside, how do we get to the interoperable learning system described in The Office of the National Coordinator of Healthcare Information Technology’s Interoperability Roadmap?

In my blog post on the Roadmap (Will Today’s Payer Have the Role they Want Tomorrow?), I argued that we must include payers in the clinical connectivity movement to have a chance.  My friend John Moore at Chilmark Research responded with an astute critique, “The relationship(s) between payers and providers is typically not one built on a whole lot of trust. I have not seen vast and growing evidence that this is occurring—yet.”

Of course John is correct—payer-provider antagonism is deeply rooted. But imagining that we can deliver reform without addressing pervasive industry distrust is an illusion.

The truth is, trust is in short supply across the healthcare ecosystem. Doctors don’t trust lawyers or even the regulators whose regulations the lawyers enforce. Specialists often don’t trust their hospital employers to be transparent on financial productivity. EMR vendors don’t trust their competitors.  Clinicians don’t trust big data systems to provide pristine “evidence-based guidance,” while big data vendors don’t trust clinicians to tell the whole truth in the clinical record. Consumers don’t trust the healthcare “research” flooding the Internet—but they’re not too sure about the healthcare establishment either.

So how do we grow trust in healthcare? It may be that the payer-provider relationship, strange as it seems, is the best place to build a new foundation.

One scholar who has devoted much of his career to the study of societal trust is Professor Roy Lewicki, a pioneer in conflict management. He points out that trust and distrust are not true opposites: “contrary to traditional, normative views that trust is good and distrust is bad… both trust and distrust have a valid role in managing complex relationships… trust is valuable insofar as it is appropriate to the context, and a healthy amount of distrust can protect against the risk of exploitation” (Lewicki & Wiethoff, Trust, Trust Development and Trust Repair, 2000).

Lewicki’s insights support the idea that the payer-provider relationship, while historically difficult, may offer the indispensable ingredients to grow trust. Given the centrality of the payer-provider relationship to the core concept of reform (increase quality while reducing cost), this could be key to our national success.

Lewicki suggests the best way for organizations to increase trust is to use a contractual framework to demonstrate competence, consistency, predictability, empathy, and sharing of control—repeatedly, and over time. The VBR contracts proliferating between payers and providers, underlying new risk-sharing agreements, present an excellent platform for the development of mutual trust along these dimensions. Successful VBR contracts require competent performance by payer and provider, detail the sharing of control in key areas such as Medical Management, and specify the metrics and methods by which performance will be judged. The sheer number of such contracts across multiple payers and insurance products provides health systems with unparalleled opportunity to evaluate the trustworthiness of each payer as partner across multiple contract cycles. 

Lewicki goes on to suggest that it is equally important to decrease distrust –which certainly rings true in healthcare. Once again, he focuses on the central role of formal contract agreements to enable clear specification of each party’s obligations. The contract can then specify how each party’s actions can be monitored and verified, under the protection of legal recourse and supported by the existence of third party arbitrators.   

Compared with the payer-provider relationship, no other “axis of distrust” in healthcare offers such rich, powerful, or frequent contract mechanisms that can establish the repeated demonstration of trustworthiness. What’s more, the government’s growing role as the ultimate payer means that critically important standards of behavior and objective third-party regulation are increasingly transparent and available.

We at NaviNet are seeing the trust-building process play out at an accelerated rate around the country. It may be more exciting to suggest that providers are suddenly going to become payers and put the dreaded insurer out of business, but it may be more accurate to focus on the mainstream of health systems who are experimenting carefully in sequential product-specific partnerships with selected payers to explore roles, responsibilities, risks and rewards in new collaborative contracts.  This will be at least as true for the health system “payviders” who are trying to become insurers themselves, typically in close cooperation with a payer-based “value-based TPA” partner, as they develop internal payer functions such as Utilization Management for the first time.

The ONC and academic reformers could miss a golden opportunity by ignoring this trend. By the time clinical interoperability could possibly be accomplished by “provider-only” means, healthcare industry structure will have been changed utterly by virtue of the innovations spawned by cooperation between payers and providers in shared risk for Medicare Advantage, Managed Medicaid, Exchanges, and commercial ACOs.  In Darwinian fashion, the healthcare entities who thrive in reform will have learned to build trust between payer and provider functions by proving to each other that they are competent, predictable, and trustworthy by means of repeated cycles of shared-risk success in VBR contracts.

 

Frank Ingari is President and Chief Executive Officer of NaviNet, Inc., America’s leading healthcare collaboration network. NaviNet helps payers and providers boost care quality, lower costs, and improve population health management with NaviNet Open, its payer-provider collaboration platform. @FrankIngari