Pioneering Ideas

A New Hope? (…but what about that pesky death star?)

Picture a version of the Star Wars opening crawl:

A long time ago in a galaxy far, far away. . . . It is a period of enormous change and worry. The challenges are great. The status quo of poor health care quality and crushingly high costs is bearing down on the people—but that enemy is also under attack. A growing band of folk from all parts of the galaxy are attempting to bring every imaginable force—technology, market, government, people power—to the cause.  No one’s certain how it will all turn out… 

Now, cue ominously Darth Vader’s imperial march theme… (Fade out).

On June 9th I participated in the 2011 HHS/IOM Health Data Initiative Forum and self-styled “Data-Palooza”.  It was exciting.  Lots of dynamic leaders attended —from the government, the software development world and other industries—lots of Twitterati—social media personalities.  The place buzzed, literally.  (It was just missing the Tatooine bar music.)

I couldn’t help but flash back to last year’s markedly more freshman, inaugural meeting and compare.  The differences one year later were striking—even startling at times.  The obvious progress could make one pretty hopeful.  The vision of creating tools that use previously moribund federal (and other) data in unique ways to solve real problems is already bearing some remarkable fruit.

During the “Data-Palooza” plenary session, a parade of app developers demonstrated technology that mines and harnesses data for very cool, practical purposes.  High points: PatientsLikeMe;  Asthmapolis; and Multistate Foodborne Disease Outbreak Investigation System  (catchy name…).  The whiz bang, jaw dropping technology of these, and other, examples was impressive.  Last year, one really had to suspend to imagine how all this talk might actually have a major impact.  This year it could seem as if the vision isn’t keeping up with the technology.  In fact, perhaps we should be bolder, much bolder.

But, then, the enormity of the challenge brings one right back down to Earth—or rather—Endor.  In spite of the great hope all this vibrant creativity inspires, one wonders about the potential, even cumulatively, of these new app tools to make a dent on our high cost, low value care problems.  In the closing session, Tim O’Reilly pointedly noted that unless we find ways to move the embedded status quo health care incumbents aside just a bit—or at least find ways to open markets so that new approaches can take root, thrive, compete—all this work will be terrific—but ultimately not game changing.  The status quo will soldier on, as always.  In my daydream (read nightmare) I started worrying that these new technological wonders would, rather than triggering imperial defeat, instead end up being like Ewok wooden spears bouncing ineffectually off the usual huge armored imperial Walkers.

But all is not lost, of course.  As we know, the rebels did ultimately destroy the death star and defeat the empire.  They did it by working together and not relying on any single silver bullet (er, blaster) or group or approach.  The new technology on display last week that helps people practically use data to solve tough health and health care problems is incredibly important.  We just need to make sure that we’re also simultaneously doing all the other necessary things—like improving market information, adjusting payment to reward high value, waking up the sleeping health care consumer and supporting our Jedi health professionals—to allow innovation to do what it should be doing for us.  That is, we need to create the conditions that will allow creativity to help us rapidly achieve sustainable high value care focused intensely on and built entirely in partnership with the patient and consumer. 

Cue epilogue theme.  (Roll credits.)

 

Up next? Oral Health.

“Can you imagine a time when we fully incorporate mental and dental health into our thinking about health?  What is it about problems above the neck that seems to exclude them so often from policy about health care?”  That’s what Institute of Medicine President Harvey Fineberg asked in 2009.  On April 8^th the IOM released a new consensus committee report, “Advancing Oral Health in America”. That committee’s 2011 response to Dr. Fineberg was essentially—“not this time—change starts here.”  I had the great privilege of participating on that committee along with 14 others from a variety of backgrounds and expertise.  Certainly, we were daunted by the enormity of the nation’s oral health challenge but also hopeful that there are, in fact, tools and approaches that could begin to make a difference. 

The IOM convened this committee based on a 2009 HRSA request for recommendations on a potential HHS oral health initiative.  The committee deliberated for almost a year while the long and contentious health care reform debate reverberated.  The specific charge for this committee was relatively narrow:  to provide strategic recommendations to HHS, specifically, regarding a department-wide oral health initiative.  Nevertheless, the national health care reform debate only served to highlight the concurrent need for reform in both oral health as well as health care, overall. 

And there were a few ghosts in the mix, so to speak—namely past reports, statements, actions, initiatives in oral health—good faith efforts all—juxtaposed against the harsh fact that the problems remain.  More than 10 years prior, the surgeon general issued a landmark report entitled, “Oral Health in America”.  It described the poor state of oral health as a “silent epidemic”.  Unfortunately and in spite of that warning, that epidemic remained altogether too silent.  In fact, arguably, nothing fundamentally has changed in those 10 years.  Entirely preventable oral diseases remain prevalent.  Oral health is part and parcel of overall health care—but the professions treat them as distinct and separate.  Vulnerable groups continue to suffer from disparate oral health outcomes. 

Even potentially more disturbing—we now recognize we’re essentially “flying blind” when it comes to the quality of oral health care.  Literally, we simply do not know much about the quality of oral health care for a variety of technical and policy reasons.  We don’t have great data sources for oral health care measures.  Even if we did, we do not have quality metrics to assess the quality of oral health care.  That’s fairly worrisome if one extrapolates from the overall health care experience in quality measurement and improvement.  In overall health care, once we started measuring the quality of that care, that’s when the scope of safety and quality problems—not to mention cost and value issues—really began to surface.  In oral health care right now, we don’t even know what we don’t know. More to the point, there’s no reason to think oral health care will be different than overall health care—and it could be worse—much worse.  In any event, it’s not acceptable to assume high quality in oral health care.  The public and our dedicated health professionals deserve to know.

So, the stakes are high—this report on improving oral health absolutely must be different than past efforts—but how?

The committee reviewed mountains of evidence, testimony, and specially commissioned reports.  From that evidence, the committee provided seven recommendations to the Secretary outlining specific steps to change the way the department approaches oral health as a governmental agency—and the way the department helps promote and lead improvement in the nation’s oral health.  Those recommendations ranged from (1) specific things the department should do to prioritize efforts—including an explicit challenge to open the initiative to patient and consumer participation, oversight and leadership; (2) an emphasis on strengthening prevention, promoting health literacy, and dramatically improving the ability and capacity of the health professions to address and improve oral health; (3) a focus on developing innovative new delivery system and payment strategies to support high value oral health care; (4) concerted efforts to use an ever expanding array of data for research—and, importantly, to develop and construct a range of oral health quality measures on performance, cost, efficiency and outcomes—and then make that information transparent and useful; and finally (5) an explicit challenge to HHS to hold itself publicly accountable year after year for action and improvement.

Of course, only time will tell if some new group 10 years hence looks back on this report as a turning point in improving the nation’s oral health—or says nice try, back to the drawing board.  We on that committee sure hope that the answer is—and the nation critically needs it to be—the former.

[These comments are the personal views of Dr. Painter and do not represent a statement by the IOM.]

Which way transparency Nirvana?

First the good news—many are pushing the envelope on public reporting of health care information these days. For instance, this week the HHS/Health 2.0 Developer Challenge awarded honors to a new mobile app—using Hospital Compare data in new and innovative ways—try it. This application maps and provides some quality information as well as immediate ER waiting times for nearby hospitals. The idea of this app challenge, as you know, is to unleash moribund federal information, such as that sitting in the creaky Hospital Compare—to innovative types who will take it and create new—and, ideally, useful ways to present the information.  That’s an exciting turn that makes altogether too much sense.

Then Wednesday, I had the good fortune to attend a very thoughtful AHRQ sponsored meeting on public reporting of care information for consumers.  The meeting included a good mix of consumers, employers, regional alliance leaders, health professionals, researchers and others.  Bill Roper provided a motivating keynote. The messages ranged from overt optimism about the important role of public reporting in the drive toward sustainable high value care—to the sober assessment that although public reporting has matured (some)—we may also be reaching limits.  As Steve Jencks commented—we’ve made progress—but let’s keep some perspective here—public reporting still needs some quick wins—it “isn’t quite covered in glory, just yet.”

Meredith Rosenthal, in her plenary presentation, observed that public reporting is essentially about to graduate from high school—sitting in the guidance counselor’s office trying to decide whether to go to college or trade school.  Bob Galvin, in the closing session, added—that while public reporting is indeed in the guidance counselor’s office—and it clearly has a bright future—it’s a pretty confused student.

The problem? There seems to be near unanimous sentiment—at least in this group—that public reporting of quality and cost information is critically important to drive sustainable health care quality and value. Still, after 25 years of trying it remains a hard slog. One line of thought is: stay the course!  We just need to keep trudging.  The holy land is right over the next hill—measures need a few more tweaks.  All we need now are those outcome measures that the real people actually want.  We definitely need a lot more engaged consumer activists and patients to help create those useful measures.  Everyone needs help getting to the right presentation of that information—presentation that will tip the scale, make the difference—and then accelerate our long, twilight march toward high value care.

Or maybe not.

What if, instead, we already have a large chunk of the public actively engaging with health care information, such that it is—on HealthGrades, WebMD, Consumer Reports, Aligning Forces for Quality sites, Hospital Compare?  Bob Galvin in his comments estimated, say, 10 to 15 million people already.  What if we’re not actually going to get many more?  What if we’re not going to see an enormous marginal return in new numbers as we struggle to improve publicly reported measurement incrementally?  What if more and more of the public are not going to wake up one day and jump online to sort through ever more complicated information to make decisions?  Certainly, our currently motivated “mavens” need better, more usable information. But these mavens also may be the actual, ultimate consumer audience—when it’s all said and done.

There is another point—perhaps we should accept that sometimes people simply act on price—just price. Price can, in fact, be a very strong information signal—and extremely user-friendly—especially when people are first dollar sensitive.  Certainly, that’s not always the case—many people will avoid the cheapest care at all costs—because, for instance, they may be terrified of getting “cheap bad” care.  But still—no arguing about it—in the right circumstances price can move markets.

In his closing comments on Wednesday, Galvin provocatively suggested some nuance here.  Perhaps we should recognize that those important mavens out there will be mavens—and then work hard to get them the best measures and tools they need to make good recommendations and decisions.  And maybe we should also accept that for some things—some procedures, images, prescriptions—individual people will be, well, deal searching consumers—and will shop avidly, as we want them to do, for the best bargain—in those limited instances.  If that’s the case, let’s help them.  In addition to developing better, publicly reported quality and cost information for mavens, we should accelerate work significantly to identify those price sensitive activities for everybody else and rapidly develop (no easy task) that price information.  But really—and not to be too flippant—why not slap some useable, accurate prices on those items pronto—and let the bargain hunting begin?

 

 

Control Freaks

Who’s driving in this relationship anyway—us or them? 

I distinctly remember my 1970’s fourth grade summer Weekly Reader (showing my age) that described a not too distant future when self-driving electric pod cars would transport human passengers, attaching on and off highways of magnetic strips. They’d be safe, clean and efficient—because the people of the future would value those attributes.  That vision, of course, hasn’t materialized. (Yet?).  

Last week, though, at TED2011 with Google’s self-driving cars we got a glimpse of a new emerging potential reality. That potential is definitely more tangible and recognizable than my Weekly Reader vision—better in some ways—certainly more prosaic and believable. In fact, I can attest that it is indeed right here, right now.  This just might be where things get pretty interesting—and disconcerting.

At TED, steady lines of politely waiting, very curious “blue jean-eratti” piled into a souped up Toyota Prius to go-kart around a parking lot for a few minutes.  Those human pioneers eagerly turned over the driving controls completely to the car computer—putting their safety and lives in its hands.  No big deal, right?  I took some Droid video during my test—see what you think. 

 

 

 

When our turn came, three of us along with a Google engineer jumped into the banal, familiar interior environment of a Prius.  The Google driver pulled around to the starting point, then announced that he was turning over control to the car and released the steering wheel.  That’s when the familiar turned, well, alien.  The car, who (and I mean who) had been patiently waiting its turn, expertly took the reins—and literally peeled out across the lot, weaving through and around the orange cone course.  We all laughed and yelled spontaneously with delight and, admittedly, some nervousness—watching the wheel turn by itself—listening to the tires screech, feeling the acceleration and braking—all without human intervention.  Our anxiety was both for our immediate safety—wanting to believe that the computer knew what it was doing—could see its way around the course.  But there was something else too.  This new experience may have very big implications—at least that seemed to be the consensus of the folks who waited in line with me.  It now seems almost inevitable—just a matter of time.  How long will it actually be before we begin to mostly or even entirely turn over the driving task to the machines?  Five years?  Ten?  Sooner?

But there’s more.  Last weekend in her New York Times column, Maureen Dowd ("Have You Driven a Smartphone Lately?" ) turned her critical wit on the new 2011 Ford bells and whistles computer dashboard.  She asserted that the automaker was irresponsibly creating essentially a public menacing, driver distracting smartphone on wheels.  At TED this week, Bill Ford got to present a different view.  He described a disastrous, pending, perpetual global traffic gridlock—as the sheer number of cars grows exponentially across a rapidly developing world—unless we design our way out of that particular scenario. Ford’s design focus is based on a car oriented future, obviously.  Some criticized that view.  He also seemed to imply that the new powerful onboard computer dashboards are easing drivers toward a time when those pervasive computers not only entertain but also pilot—freeing the driver and passengers to work and play while traveling.  The smart cars will also soon communicate with other cars and devise the smartest, safest, fastest routes to and from destinations—and, importantly, avoid pedestrians and cyclists along the way.  Obviously, Dowd’s safety points resonate.  Distracted driving hurts and kills thousands annually—it’s an immediate and terrifying public health challenge.  Technology that potentially promotes distraction is dangerous.  Ideally, our advances would build toward the future emphasizing safety first—before entertainment and convenience.  If only. 

In any event, if there was any doubt about the rapidly proliferating power and real world potential of self driving technology, the Google demo just completely snuffed that.  And, to my initial point, that’s more than a little disconcerting.  Like many of you no doubt, I’m a horrible back seat driver.  I did, luckily, survive my brief test drive—er, ride—into the future.  Before last week, as much as I love my Droid and other gadgets (and I do), there’s likely no way I’d have said we’re ready to turn over the wheel to those gadgets.  Now, honestly, I’m not so sure.  In fact, that transfer may come soon—very soon, ready or not.

What if Superman’s a YouTube Hero?

Picture this—a 51 year old on a recent transcontinental flight with nose poked into an iPod Touch watching a documentary—tears streaming.  My co-passengers almost certainly noticed—not clear what they thought.  I have no idea why I downloaded “Waiting for Superman” the day before my flight to this week’s TED2011 in Long Beach.  I had intended to watch that movie for months—but just hadn’t found the time.  Whatever the reason, the last minutes of that film hit me hard.  It’s ironic because just a few days prior, I posted on Facebook about a different movie: “127 Hours”.  My Facebook post gamely highlighted that movie’s disturbing intensity as an intrepid, solo hiker finds himself literally swallowed and held by a desert canyon—with his right arm essentially and permanently trapped by a fallen boulder.  The character played by James Franco is forced to make a horrific life or death decision—no one was coming to rescue—ultimately he chooses life and saves himself.  My post pointed out that “127 Hours” wasn’t for the squeamish—and I wasn’t squeamish. 

 Given that bravado, it’s curious that just days later I would go to pieces when those “Superman” kids and their families in spite of their best desperate efforts, couldn’t find a way out of their own entrapment.  The kids don’t even get a real choice—they’re just stuck.  I get that the topic is hard, complicated, controversial—but for me, that failed school tragedy is not about “the teachers” or “the unions” or silver bullet solutions like “charter schools”.  Nope, my tears weren’t about the adults at all; rather, they were for those kids (and all the kids) trapped in failed and mediocre schools without choices or options and what that entrapment means for their lives.  Obviously, we can and must do better—we can’t leave them stuck in deep failed school canyons; they need our help. 

On the plane earlier this week all I could do was weep ineffectually.  You can imagine my surprise when upon arriving at TED I found a “Waiting for Superman” DVD in the pre-meeting materials. (Cue Twilight Zone music…).  That might have been that—just serendipity—a coincidence to ponder—except yesterday afternoon during a session called “Knowledge Revolution” curated by Bill Gates, enter Salman Khan with his well-received TED presentation. (See mention in great Day Two Summary)  It seems Mr. Khan left his hedge fund job a while back because he’s passionate about teaching kids.  In fact he’s so passionate about it that he did something amazing—creating, so far, over 2,000 YouTube video lectures on a range of topics now posted  here.  All these video lectures are free and available to anyone—they’re also wonderful.  Khan says kids can watch the lectures at home and do practical homework tasks together in the classroom—reversing the current teaching mindset.  His site includes sophisticated tracking capabilities for teachers—so teachers will know who’s mastered what topics and who needs targeted help.  Also, kids who have mastered certain areas can serve as mentors for peers who haven’t.  In fact, with these powerful tools, the learning environment is not contained to the actual classroom.  There’s no reason, he says, that a student in Calcutta couldn’t help a child in Kansas City—and vice versa.  Khan, in fact, envisions a global, one world classroom.  Yesterday, that inspiring vision brought the TED crowd to their feet with loud, joyful cheers.  Maybe there is hope.  Maybe we, the adults, need to solve this intractable entrapment by thinking, collaborating and acting in a multitude of radically different yet reinforcing, out of the box, ways—and do it quickly—for our stuck kids.

Spread.

What is an idea worth spreading?  I almost fell out of my chair here in Long Beach, California yesterday at TED2011—a couple of times, actually. (Here’s a great overview of Day 1)  In addition, though, to the big tent main sessions—spectacles you might even say—the week long event includes some slightly lower key, somewhat intimate venues that highlight wonderful talks by various folks with great ideas.  One of those was yesterday morning by Charles Roberts from the Royal Institute about addressing climate change.  Of course interesting—yet it could have been more of the same—until he started linking to some pretty universal truths.  Roberts lamented that many current efforts to address carbon reduction struggle because of market dysfunction or in many cases occur in settings that completely lack market forces that might prompt carbon efficiency.  He then ticked through the things that might help generate some market functionality—things that could prompt companies, like for instance airlines, to step up and address their carbon issues.  Those tools include…wait for it…consumer engagement, widely available information, incentives.  He suggested a system to rate companies based on how those businesses address their carbon footprint.  It would, he noted, be quite important to report those measures publicly.  He described some matrix roll up scores that summarize past, present and future possible carbon efforts.  His system would rely on competition with financial incentives in which customers sought out companies with better scores—and rewarded those companies for decreasing their footprint.  One reason his points resonated—we designed our very own RWJF Aligning Forces for Quality based on many of the same tenets.  Of course, Aligning Forces is an effort to address a different, but arguably similarly intransigent complex adaptive system problem—stubbornly persistent mediocre health care quality and value.  Nevertheless, in Aligning Forces what tools did we and our experts land on?  You guessed it: consumer engagement, measuring and reporting, improvement resources, changing payment to reward better, more efficient care outcomes—all to correct a fundamentally dysfunctional marketplace. Sometimes a new idea, I guess, can also mean taking what we know and applying it, spreading it even, to new hard problems in different ways.