The Daily Beat

What you should care about in healthcare today, from the editors of Becker's Hospital Review

Why Apple, Epic and IBM will take over healthcare

The three will emerge as healthcare's ruling triumvirate. Here's why.

Apple and IBM recently announced they were putting aside their 1980s rivalry to come together to develop a new set of business-facing mobile apps for iOS powered by IBM's big data capabilities and enterprise platform expertise.

One of the new partnership's main focuses is healthcare, says IBM's general manager for the public sector Dan Pelino. The healthcare-focused apps that will come out of the partnership will "make patient information mobile, and it will be safe and secure," he says. "It will be enterprise solutions that take advantage of the mobile device [iPhones and iPads] and the security and scale IBM is known for."

The partnership brings together two companies that have been rapidly expanding their presence in the healthcare industry. Beside being "under the covers" of many health IT system implementations, IBM has been working with several healthcare providers to use Watson's natural-language processing capabilities to improve care delivery with some impressive results, and has offered some healthcare app developers access to Watson's application programming interface to expand the use of the technology.And Apple recently announced HealthKit, a consumer-facing mobile health-tracking platform able to integrate with other health apps and monitoring devices to help users more easily monitor their own health.

What has made both companies' forays into healthcare that much more formidable has been their close relationships with Epic. Epic has partnered with Apple before on EHR apps and worked with Apple on HealthKit, paving the way for providers' Epic systems to integrate with the platform and opening up possibilities for remote monitoring and care coordination. IBM, already involved in about 80 percent of Epic implementations, recently tightened its ties to the electronic health record giant when the two announced a joint bid for the Department of Defense's EHR modernization contract (according to an InformationWeek article, a feature of the bid is iOS support).

Mr. Pelino is quick to clarify that Epic is not an official part of the new Apple-IBM partnership, though says the three companies will continue to work together. And together, I think they will emerge as healthcare's new leaders.


Steve Jobs didn't disrupt, he adapted. So should healthcare.

Healthcare is poised for disruption, and if the leading theory on disruptive innovation holds true, the leading organizations in the industry today will not be the ones to bring about that disruption.

But as I've written previously on this blog, that doesn't mean all existing organizations will perish. In fact, as I read more on Clay Christensen's theory of disruption and change management in general, the less I believe in the idea of 'disrupt or die.' 

The industry will no doubt be disrupted, but it's false to believe that all but the disruptor will be relegated to failure.

Instead, those that succeed and those that fail will be distinguished by one thing: how they adapt in the face of disruption.

As disruption changes the industry, the organizations that will continue to thrive will be those best able to adjust their business models and practices to industry changes and external threats.

Consider Apple and Microsoft. Today, Apple is known as the disruptor, maker of such innovative technologies and the iPhone and iPad. Microsoft, which had decades of success as a software stalwart, recently announced it will lay off 18,000 workers as it shifts from a "devices and services" strategy to a "productivity and platform company." 

Yet, Apple wasn't always on top. In the 1990s, after the departure of its founder Steve Jobs, Apple was faltering. Microsoft, on the other hand, was the bell of the tech ball, having launched its Windows 95 in 1995 with 7 million copies sold in five weeks

Jobs was brought back in to revitalize Apple, and revitalize the company he did. In 1998, Apple launched the iMac — the first personal computer without external storage, and a fun, colorful design. Some would argue the iMac was disruptive, and in some ways it was. In other ways, it was simply the next iteration of the personal computer — an adaptation, albeit a bold one, to its Macintosh introduced some 14 years prior.

Adaptation is a word that is used often by John Kenagy, MD. Dr. Kenagy has become a prophet of sorts for the power of adaptation in healthcare, studying under Clay Christensen at Harvard and later introducing the theory of "Adaptive Design." The theory is essentially a set of principles, specific to healthcare, to help organizations successfully adapt in the face of change — and do so in a way that delivers exactly what the patient needs, all while lowering the cost of care.

A practicing physician for many years, Dr. Kenagy didn't worry too much about organizational culture and processes until he broke his neck. Yes, you read that right. After a fall while climbing a tree with his young son, Dr. Kenagy's months-long recovery allowed him to observe breakdowns in healthcare firsthand. He entered management after the accident, and while studying management at Harvard, was exposed to the principles of the Toyota Production System — the principles of which serve as the foundation for Adaptive Design.

Two pathways of innovation
Disruptive innovation and adaptive design are different ways of approaching the same idea: innovation. They represent "two pathways of innovation," says Dr. Kenagy.
"Rather than calling innovation disruptive, I believe innovation is an adaptive process," he explains.

When disruption comes from an outsider, an adaptive culture can adjust its organization so it can continue to find success, even if it's under a new world order.  

What separates those that can adapt from those that fail?


Is Walgreens doing more for population health than you?

Last week, in a rather quiet announcement, Walgreens launched an extension of its "Balance Rewards" program that might just strike fear in any healthcare executive worried about the growing competitiveness of retail health.

Walgreen's new Balance Rewards for healthy choices™ initiative extends the retailer's loyalty program to reward members for participating in various health-relatWalgreensHealthyChoicesed programs and tracking progress toward health goals.

Balance Rewards members earn around 10 points for every $1 they spend at Walgreens. Under the new 'healthy choices' initiative, members can earn 250 points for setting a personal health goal, 20 points for every mile they walk or run and 20 points for weight tracking each day, among other incentives. Once a member earns 5,000 points, they earn a $5 dollar credit toward any Walgreen's purchase.

Members can enter the information through the Balance Rewards website, or by downloading a Walgreens app. The app is compatible with some 40 wearable devices and apps, including Fitbit, iHealth and MapMyFitness, so members can automatically sync their fitness data into the program app and earn points without lifting a finger.

The program is rather ingenious on Walgreen's part. It encourages healthy behavior, makes the retailer part of the healthcare solution, and drives traffic to Walgreen's website and app (where promotional information can be seen by users) and retail locations. Insurers can even sign on to set up specific goals for their members.

There are 8,215 Walgreens stores in the country, and 8 million Americans visit a Walgreens each day(!). There are three within a five-minute walk from my office here in Chicago, and an informal poll among Becker's workers found most of us visit a Walgreen's store more than once a week.

The launch of the program is yet another noteworthy move by the company to further brand itself as a healthcare provider — and not just a corner store that sometimes fills your prescriptions.


Has Patient Satisfaction Gone Too Far? — The Case for Jerks in Healthcare

Among healthcare leaders, there has been a call to arms of sorts, which has swelled over the last five or so years, to rid medicine of, well, jerks.

The more technical term we've been using to describe this phenomenon of clinicians (mostly physicians) who are condescending, argumentative, aggressive and/or refuse to play well with others is "disruptive medicine."

In 2008, The Joint Commission created a new policy classifying disruptive behavior as a sentinel event, urging the organizations it accredits to take a zero-tolerance approach toward such situations.  


According to TJC, disruptive behaviors include "overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities."

Research has shown that both overt and passive behaviors are not rare (98 percent of healthcare workers reported observing such behavior, according to a study by the American College of Physician Executives) and can be detrimental to patient safety.

As a result, healthcare systems across the country have cracked down on disruptive behavior, choosing to cite physicians rather than looking the other way — the typical response by administrators for many years. In extreme cases, hospitals have dropped credentials or fired physicians for disruptive behavior.

At the same time, Medicare and commercial payers have begun to reward clinicians for strong patient satisfaction scores. Physician groups have also begun compensating clinicians based on their scores. In rare cases, clinicians with the lowest scores could be dropped from networks or fired.

Despite trends toward kinder, more empathetic, clinicians, Wen Shen, MD, an endocrine surgeon at the University of California-San Francisco, says the push for "a kinder, gentler surgeon" is misguided.

"My profession is filled with exceptional individuals who do amazing, lifesaving work. Many of us are jerks," Dr. Shen writes in an article for Pacific Standard, a publication put out by the Miller-McCune Center for Research, Media and Public Policy. "This is the trouble with surgeons. We are a sub-tribe of doctors who have long been celebrated for our abilities yet reviled for our personalities."

He continues:

"Within the past two decades, though, the surgical profession has attempted a wholesale revamping of its image and ideals. Compassion, communication, and collaboration are now strongly emphasized during training. It’s been a rapid and turbulent metamorphosis that has undoubtedly led to improvements for patients, hospital co-workers, and even surgeons themselves. Nonetheless, in the process, surgery may have created its own identity crisis. We want to believe we’re better off with nicer surgeons. But what do we lose?"

While Dr. Shen admits many of the effects have been positive  — a 2011 survey that found patients who perceive higher levels of empathy in their surgeon have better outcomes — he worries our industry's push for more likeable surgeons may have unintended consequences.

Has our emphasis on patient satisfaction gone too far?


What the Microsoft Fail Can Teach Healthcare Leaders

Workforce reduction, downsizing, streamlining, or as Microsoft CEO Satya Nadella explained in a now-notorious memo to employees last week "the first step to building the right organization for our ambitions is to realign our workforce," all describe what most Americans would call, simply and accurately, a layoff. Another accurate description: A mass firing.

Over and over again (yes, you, Citigroup, and you, Best Buy), CEOs (and no doubt their HR and communications advisors) find the need to obfuscate what is clear to most workers receiving the email: some of your colleagues, and maybe even you, are going to get fired. They can't bring themselves to be straightforward, and they end up looking foolish in the process.

Most of the Microsoft layoffs will affect legacy Nokia employees, which Microsoft acquired last year. Perhaps Stephen Elop, former CEO of Nokia and now an executive at Microsoft, did better? Try again. Here's how he announced the layoffs to his division:

"It is particularly important to recognize that the role of phones within Microsoft is different than it was within Nokia. Whereas the hardware business of phones within Nokia was an end unto itself, within Microsoft all our devices are intended to embody the finest of Microsoft’s digital work and digital life experiences, while accruing value to Microsoft’s overall strategy. Our device strategy must reflect Microsoft’s strategy and must be accomplished within an appropriate financial envelope. Therefore, we plan to make some changes."  


Microsoft and Nokia have a largely professional workforce, and still that paragraph probably left most of their heads spinning.

How do organizations with a less skilled workforce 'obfuscate' a mass firing?

The good ones don't.

Just say it
People feel better when they have clear, transparent information. Even if it's bad it feels better than uncertainty.


What It’s Like to Use Telemedicine as a Patient

A recent study found the vast majority (82 percent) of young adults age 18 to 34 say having a consultation with their physician on a mobile device would be the best option for them.

On Thursday, I found out I probably agree with most of my peers.

I tested out a mobile app from American Well, a telemedicine company that offers remote physician consults for minor, acute conditions. I wasn’t sick, but the public relations representative from American Well assured me I wouldn’t be disturbing their physicians.

So I downloaded the app to my smartphone, created a passcode and entered my basic personal information and then was taken to a “Choose Your Provider” screen. Available physicians in my state of Illinois, along with their pictures and specialties, were listed. I selected the first on the list, Ingrid Antall, MD. The app prompted me to describe my condition (I confessed to being a journalist), select a pharmacy for prescriptions and enter my credit card information for the $49 charge for the 10-minute consult (I tested the app for free, and users can enter their insurance information if their plans cover the service).

The first attempt to connect me to Dr. Antall failed, though it was more than likely due to my wireless Internet connection. On my second attempt I was connected, and was able to see Dr. Antall at the bottom of a split screen.

We talked for a bit, and she told me what usually happens during these consults. She said the online visits are similar to office visits — she takes the patient’s history and then conducts a physical exam.

Of course, a telemedicine physical exam is slightly different. Dr. Antall said she’ll have sinus infection patients touch their own necks and cheeks and report what they feel, and patients with stomach troubles will examine their own abdomen. “Most people have never really examined themselves like that before,” she said. “It’s fun for them.” She also said a lack of medical supplies where the patients are occasionally necessitates creativity, like having patients use the smartphone light to help Dr. Antall see down their throats.


Nurses vs. EHRs: Why the NNU is Fighting the Wrong Fight

One of National Nurses United's most attention-catching new TV spots, "Nurses vs. Computer Care," portrays a hospital where patient care has been mostly given over to a glitch-ridden computer and hapless IT staffer. When a patient's condition suddenly worsens, the computer malfunctions and is unable to help. A nurse soon steps into the room.

"Don't worry, you're in the care of a registered nurse now," she tells the panicked patient. She then turns to her presumed replacements: "You and your computer are in over your heads. Get a doctor, and get out of my way."

Part of the NNU's "Insist on an RN" campaign that launched in May, the ad is designed to highlight (through acknowledged exaggeration) the union's stance that electronic health records are compromising patient care.

The problem, says NNU Co-President Deborah Burger, RN, is that EHRs are inherently billing and collections tools. "Everything is about capturing the DRG and ICD codes," she says. "They never were honestly intended for improving patient care."

Patient safety concerns emerge, she says, when EHRs' clinical decision support functionality steers clinicians toward standardized, low-cost treatment plans without accounting for a patient's individual situation like nurses have been trained to do. "[Nurses] look at the patient, not just the disease but any comorbidities, their relationship with their families — it all has an effect on treatment, so it has to be taken into account," she says.

Of course, CDS alerts and recommendations can be overridden by clinicians, and frequently are. Despite the option to ignore the computer-generated recommendation, Ms. Burger believes the presence of the CDS can still sway clinical judgment. 


Close Hospitals? Not So Fast.

A blog post I wrote last week raised the question of whether closing hospitals and firing low-performing physicians could help healthcare in the long-run. The story was based on comments from thought leaders, including athenahealth CEO Jonathon Bush, Cleveland Clinic CEO Dr. Toby Cosgrove and Dr. Ezekiel Emanuel, about America having too many hospital beds and the need for some to close and find a presence elsewhere in the healthcare spectrum.

Panel discussions at "idea festivals" can gain momentum and get provocative rather quickly, and I regret if my blog post did the same. I was not suggesting much-needed safety-nets or critical access hospitals in rural communities shutter and abandon their communities. Unfortunately, they are already doing so: 14 rural hospitals shut down across the country last year alone, according to the National Rural Health Association as cited in this Al Jazeera America report.

When 49-bed Vidant Pungo Hospital in Belhaven, N.C., closed July 1, it left the town's 1,500 residents with a 30-minute drive (at least) to the closest emergency room. There is the possibility that the distance may have already contributed to one patient's death, as it took an hour to transport a 48-year-old woman experiencing a heart attack to the next closest hospital via helicopter. The mayor of Belhaven began marching 273 miles to Washington, D.C., this week to draw attention to the closure and break away from his fellow Republicans by supporting Medicaid expansion. If North Carolina had expanded Medicaid, Pungo may be in a different spot.

Rather, the idea of closure or reduction of inpatient services was targeted more toward markets and metro areas saturated with hospitals. As my colleague Lindsey Dunn wrote yesterday, there are 121 metropolitan statistical areas (or markets) with only a 20-50 percent occupancy rate in the U.S., according to data from MedPac.

As care shifts from inpatient to outpatient and hospitals move toward pay-for-performance models — the ultimate goal being to keep people healthy and out of hospitals — the need for some hospitals to close doesn't seem so radical. For instance, Summa Health System in Akron, Ohio, recently closed inpatient services at its Wadsworth-Rittman Hospital after seeing low volumes. Rebranded as a health center, Wadsworth-Rittman will still house a freestanding emergency department and expanded primary care offices. 

Vidant Pungo and Wadsworth-Rittman's situations are different, but same can be said for each and every healthcare market, which is one problem in discussions about "hospital closures" being helpful. Given a community's political circumstances, demographics, and other confounding factors, a hospital closure can mean any one of a hundred different things.

Alan Sager, PhD, a professor with Boston University School of Public Health, called me earlier this week to talk about the inherent problems in viewing hospital closures as a solution to healthcare's cost and quality problems. First and foremost, he says overbedding is not a cause of high cost in U.S. healthcare.


America Loves Getting Bigger, and Therein Lies the Problem for Healthcare

I'm a big fan of Morgan Spurlock. If you don't recognize the name, he's the guy that, back in 2004, ate only McDonalds for 30 days and made a documentary about it. (For the record, he gained nearly 25 lbs in the 30 days).

The problem with McDonald's, Spurlock argues, isn't the food itself. While it wouldn't be considered health food, a regular McDonald's hamburger has just 250 calories and 9 grams of fat. Instead, what makes McDonald's so detrimental to our health is that it encourages us to 'supersize' everything — causing us to eat more than we need, and more than we would have eaten without the 'supersize' prompt.

Why do Americans say yes to supersizing? 

Because in America, bigger is better — or at least, that's been the way of thinking for a long time.

The same accepted wisdom has been alive and well in healthcare for decades. 

"It's America. We don't make ourselves smaller," said Kenneth Kaufman, managing director and chair of healthcare consulting firm KaufmanHall. I spoke with Kaufman a few weeks ago about various trends in healthcare, including consolidation.

"A lot of these organizations would be much more effective in the future if they were smaller. They're too big," he explained.

In 1975 there were more than 7,000 hospitals in the U.S. Today there are 5,700. Despite having fewer hospitals, the occupancy rate has also declined. In 1975, 76 percent of hospital beds were filled. In 2012, the rate was 61 percent. In fact, in the six years from 2006 through 2012, the average Medicare inpatient occupancy for the country declined 13 percent, according to MedPAC. Even more telling, there are 121 metropolitan statistical areas (the technical term for 'market') with only a 20-50 percent occupancy rate in the U.S.

Our country is over-bedded.

We've seen the affects of this by way of hospital closures and significant consolidation — both of which are likely to continue as medical advances and preventive care help keep more patients out of the hospital.

What does this mean for healthcare leaders?

There will be fewer hospitals.


What Wayne Gretzky Can Teach Healthcare About Transitioning to Pay-for-Performance

Hockey great Wayne Gretzky played 20 years in the National Hockey League, earning his place as one of the most talented and celebrated athletes in the sport in the late 1970s through 1990s. I lived just outside St. Louis in 1996, his one and only season with the team. When he was traded from the Kings, the excitement for his arrival was electric.

Wayne Gretzky had incredible physical talent, but like any superstar athlete, what separated him from the rest of the very talented professional athletes he played against was a mental and intellectual edge.

One of his most famous quotes (I remember a high school friend with this exact poster hanging on his wall) is this: "I skate to where the puck is going to be, not where it has been."

The way he played the game wasn't to race over to where he saw the puck, but to anticipate where the puck would be next, and go there. The approach certainly served him well.

Gretzy's quote recently came up in a conversation I had with Kenneth Kaufman, managing director and chair of healthcare consulting firm KaufmanHall. Kaufman mentioned it as we were talking about hospitals' difficulty in transitioning to value-based payment models.

Specifically, we talked about how so many health system executives and boards are looking for guidance in timing the jump from fee-for-service to a new model (an issue that I previously wrote about here). That approach (i.e., 'timing' the transition) misses the point, he said. 

If Wayne Gretzky were a healthcare consultant, he would agree.