Archive for the ‘Looking Ahead Columns from the Health Forum Journal’ Category

There's No Screen

Sunday, January 6th, 2002

Techno-futurists are full of it. Technology doesn’t cause anything. It amplifies, distorts, leverages, and attenuates but it does not determine the direction of things. It neither creates flattened organizations nor hierarchical ones. It is neither the cause of centralization nor decentralization. Technology, in general and, information technology in particular, is neutral in both a geographic and organizational sense.

This was the guts of my Ph.D dissertation almost twenty years ago. Like most dissertation writers I was so sick of it when I finished that I didn’t want to look at it again, let alone publish it or talk about it with anyone. So, I was delighted when a friend passed along to me The Social Life of Information by John Seely Brown and Paul Duguid of Xerox PARC fame (Harvard Business School Press, 2000). The guts of their argument is more wide ranging, more scholarly, better written and more readable than my dissertation, but the stance is the same. Futurists and technologists invest too much faith in technological determinism and not enough in the importance of the social context of technological change.

Becoming digital in healthcare will require much more than computers and bandwidth. It will require the correct social, political, and economic context and the organizational and personal transformation to bring out the best in the machines. And the transformation needs to make healthcare truly better not just appease the technologists.

In just one day, today I was reminded of how far we have to go. At 7.00 am I was on the phone with the CEO of a data-mining company, who has successfully applied sophisticated data-mining and pattern recognition technology to the oil exploration business. The CEO, a cancer survivor, wants to: “apply the (data-mining) technology to healthcare, so that doctors could have a synthesis of all the best information available to them on the screen, as they treat the patient”. “What screen?” I asked. “There’s no screen. No books even. ” I said. “Doctors don’t think like that, they like to make it up as they go along. It’s hypothetico-deductive reasoning at best, not calculus.” He was a scientist and that got him.

Fast forward an hour. I am going for a second opinion about whether I need neck surgery for a herniated disk. A week ago, the head of Neurosurgery at Stanford University told me I need it, and I believed him, but hey I’m supposed to be an informed consumer, so I’m at the high-priced sports medicine guys who don’t do surgery to see a non interventionist neurologist. Fancy office buildings, beautiful art, smart staff, yet the same opening ritual at reception as in all American healthcare: they took a xerox copy of my insurance card. (Wouldn’t it seem sensible to make the cards a swipe card or something?). I get ushered into an exam room, give the nurse the history, and after a bit of a wait, the neurologist bounds in. He does a lot of touchy feely exams, he asks me questions, he goes into trance like reflections at times. He hits me with a little rubber hammer all over the place, including between the eyes. There’s no screen.

I came to him hoping to be told that I didn’t need surgery. He told me I did, and immediately. I don’t need the screen. I trust him.

A couple of hours later after I cancel all my obligations for the next few weeks, I’m on another conference call. This time it’s with senior officers of the American Heart Association, the NIH, and the US Public Health Service talking about a conference they are organizing next year on cardiovascular health. The goal of the conference is help a wide range of practitioners and public health folks discuss ways to reach the healthy 2010 goals set by the Surgeon General. Among the wide range of problems we discussed, one was clear: the lack of compliance by patients and physicians with the existing knowledge about cardio-vascular health and management of disease. An eminent cardiologist on the call, who is also head of a large group practice, explained how in his practice, the cardiovascular care guidelines pop up on the screen to remind the doctor at discharge about the appropriate follow-up care. The American Heart Association is making these guidelines widely available on the screens of all physicians who want them.

There are screens, and doctors are increasingly using them. But the screens must enhance the science and magic of medicine. They must help not hinder the connection between physician and patient, and medicine can be even better as a result.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. A shorter version of this editorial was published in the January/February 2002 Issue of the Health Forum Journal.

The Reluctant Donkey

Tuesday, November 6th, 2001

There are only two issues in American health care. The first is universal access. The second is the need for a complete redesign of financing and delivery over the next 20 years. Why 20 years? In 2022, the peak of the baby boom turns 65. Fully 20 percent of the population will be over 65, compared with 13 percent today. We will have an aging white population expecting its Medicare to be paid for and delivered by an increasingly uninsured and increasingly minority working population. We will have dazzling new technologies and spineless politicians who will promise these technologies to the people without explaining who will pay for them. This does not compute. We can’t keep doing what we are doing.

The Institute of Medicine’s most recent report began the 20-year redesign process with some lofty ideals and practical first steps to cross the quality chasm, but the health care system is like a reluctant donkey, stubbornly resisting change. In health care we like to go to meetings about change, we don’t like to change.

The resistance to change is understandable. The U.S. health care system is bigger than the entire Italian economy. You would not expect the redesign of Italy to be trivial.

But make no mistake, we have no choice but change. And it has to start now.

Genomics is an important part of the redesign of health care. Randy Scott, founder and CEO of Genomic Health, wrote recently about the confluence of three powerful technology forces for change in health care: Moore’s law (the number of circuits per chip doubles every 18 months), Metcalfe’s Law (the power of the network is proportional to the square of the number of participants), and what Scott calls The Law of Finite Biology (all biological systems have a finite and thus knowable number of proteins, pathways, and so on). Together these forces will require the health care delivery system to redesign itself from an artisan delivery system of uneven quality to a system of mass customization: efficient, effective, and tailored to the individual needs, preferences, and genetic makeup of individuals.

Genomics will offer new tools of drug discovery, drug development, and customized clinical care. It will change the daily routine of all health care providers. At its extreme, the genomics revolution could lead to a health care system founded on public health, prevention, primary care, and prescription drugs rather than one centered on hospitals and proceduralists.

We need to flesh out alternate visions of a redesigned future. But more important, we need the leaders who can take us there. We need to celebrate the pioneers who drag the donkey across the chasm, who take the heat in the short run to show us the light in the long run. We have only 20 years, and it is a very big and very stubborn donkey.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. A shorter version of this editorial was published in the November/December 2001 Issue of the Health Forum Journal.

Compassion, Connection, and Concern

Thursday, September 6th, 2001

I grew up in Britain, in the Basil Fawlty school of customer service-customer as scum-which probably explains my low-level Maslowian view of most service businesses. I don’t need to self-actualize at my bank, I just need them to clear the checks I write (yet even this they find challenging).

All services should at least meet the basic Maslowian need of safety. Safe schools, safe airlines, safe hospitals should be a goal. The brilliance of the patient safety movement was that it set up a discussion of the lack of systems in health care by appealing to the most basic of needs. Great service companies like Charles Schwab or Starbucks have great systems (the information systems and the organizational capacity) to deliver consistent quality.

Beyond safety, most of us look for competence. Is the technical quality there? That’s harder to judge in health care-how do we know if our doctor does it right? Despite all the scorecards, most of us judge on subjective factors. Many patients in surveys claim to have changed doctors because they were dissatisfied with quality. It probably was not based on systematic analysis of the technical quality of the care, more that the physician didn’t connect with the patient, didn’t spend enough time with them, didn’t seem to care.

Comfort and convenience matter. The physical environment of health care is often intimidating, and caregivers are so harried they often don’t have time to make the patient feel comfortable. But why do we agonize over the nursing shortage and not over a bank teller shortage? Because banking has redesigned itself, with ATMs, to serve customers more efficiently. We have not redesigned health care delivery to maximize quality, customer service, and caring.

Caring is the key part of the health care experience. I am not talking about an affable bedside manner. I don’t want an excessively cheerful surgeon, kneeling by my bedside saying “Hi, I’m Bob. I’ll be your surgeon today.” God forbid that we turn the bedside into the same insincere, way-too-perky, customer service we get in chain steakhouses.

I want caregivers who recognize that I am vulnerable. No matter how smart, well informed, and empowered I may be as patient, friend, or family member, when I come in contact with the health care system I am frightened, anxious, and in pain.

Health care systems need to transform health care delivery to match the best in breed of the service industry in safety, competency, and consistency of customer service. But as we embark on the grand redesign of health care over the next 20 years, let us not neglect the caring part of the health care experience. We need to reduce medical errors, but we also need compassion, connection, and concern.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. A shorter version of this editorial was published in the September/October 2001 Issue of the Health Forum Journal.

Evidence-Based Consumerism

Friday, July 6th, 2001

In most markets, and most industries, organizations are accountable to their customers. If you make a product that doesn’t work or doesn’t meet customer needs in some other way, then you won’t make money and your shareholders will be unhappy. The magic of market forces makes firms accountable. But markets fail in healthcare. (By the way, that’s why we have a whole branch of economics called health economics and we don’t have dog food economics or Sport Utility Vehicle economics). The major source of market failure in health care, according to the Nobel laureates, is asymmetry of information-in a nutshell, doctors know more than patients. Therefore we have created all kinds of societal institutions like professions, universities, government regulators, health plans and review organizations in an attempt to make doctors and their workshops more accountable.

With the rise of the Internet and the new sophisticated consumer, some are challenging the asymmetry of information argument and asking why can’t healthcare be like other markets, and be accountable to the consumer. These critics have a point. A hundred million Americans have surfed the net for healthcare information according to pollsters at Harris Interactive. At the same time, consumers are declaring their preferences for complementary and alternative therapy and paying good money for it, out of their own pocket. Isn’t that the ultimate accountability?

Before we all get too carried away, let me suggest that there are two types of consumerism, the first is what I would call na├»ve market consumerism (this is Milton Friedman on steroids). Many in the pharmaceutical, medical products, and emerging health insurance markets subscribe to the notion that that whatever the consumer wants to spend his/her money on in healthcare is fine (and by definition utility maximizing for the consumer). So it’s the consumer’s choice, if she decides to lower her cholesterol by getting Lipitor prescribed by her doctor or by purchasing herbal remedies called “The Fat Trapper” and “Exercise in a Bottle” after she saw the infomercial. (Please note, I am not making this up, stay up late enough watching cable TV and you will know of the “Fat Trapper”).

A second form of consumerism is what I would term evidence-based consumerism. This makes the consumer a partner in the process of accountability by providing them with the scientifically based support to make informed judgment. It addresses the asymmetry of information full-on and tries to level the playing field. The explosion in health-related websites and self-help resources is assisting the consumer in overcoming their anxiety about not knowing enough. But to date, we have not made these information purveyors accountable for their counsel. We lack a system of accountability for healthcare information.

There are some signs of improvement. The FDA regulates drug information and so pharmaceutical companies are a reliable source of information about their products, although skeptics may be leery of their aggressive advertising and promotion. Similarly, the professional medical societies are playing a more formal role on the internet and will bring their professional standards (and biases) to the information exchange. This is not enough. Consumerism needs to be evidence-based, where there is a seal of approval placed on the information, backed up by the same accountability that exists in the peer reviewed scientific literature. Consumers are showing an appetite for industrial-strength medical websites (the kind that real doctors use) that are evidence-based . New organizations such as Medrock (a medical concierge service aimed at helping patients with serious medical conditions), BMJ Unified (a new joint venture between United Healthcare and the British Medical Journal), Medem and Medscape (both web-based businesses with impeccable scientific credentials) may all evolve as pioneers in evidence-based consumerism.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This essay was published in the July/August 2001 Issue of the Health Forum Journal.

The Business Case for Universality

Sunday, May 6th, 2001

We have a Bush in the White House. Cheney, Powell and Condy Rice are bombing Iraq. And, health premiums are going up at double-digit rates. It’s 1990 all over again.

1990 was the beginning of big health reform. The recession pushed corporate America over the edge and healthcare became a CFO issue. Back then, the combination of cost escalation and recession led to a massive growth in HMOs, an acceleration in the number of uninsured (particularly among the marginally employed), widening dissatisfaction with health care generally, Harris Wofford, and the Clintons. Massive government health reform offered the prospect of universality.

Don’t count on an exact replay. There was a chance to do something big and the chance was blown. But a new set of forces may conspire to bring universality to the fore again, driven by the business of health insurance itself.

Three key driving forces are conspiring to challenge the traditional health insurance system:

  • Consumer Payment for Healthcare. In pure form, defined contribution health plans are ones in which employees are given a fixed dollar contribution by employers and asked to choose among a choice of insurance options or care systems. While it is fashionable to talk about defined contribution as the next megatrend, it may play out in a more prosaic way with consumers simply paying more out of pocket for healthcare through co-payments, co-insurance and deductibles. Employers jacking up the cost sharing with employees is defined contribution by stealth. Either way it will represent the reversal of a 30 year trend where there has been progressive economic insulation of the consumer from the cost of care. When consumers have to pay more of their own money they will become even more demanding, more skeptical, and more fearful of being left behind.
  • Customization of Care. Genomics will yield new tests that tell us all about our future course of disease and health. But more important than the burden of prescience (which we futurists carry with us all the time) consumers will know that their care will be more effective if customized for them. The right drug, for the right patient, at the right time will become the mantra reinforced by the pharmaceutical industry and the morning shows. The combination of predispositional genetic tests in the hands of consumers and insurers alike with the desire for customization by consumers and technology vendors will undermine the current health insurance system. In particular these trends aggravate the three Achilles heels of health insurance: moral hazard (when you have insurance you use it); adverse selection (you buy it when you know you are going to need it); and cream skimming (we won’t sell it to you if you really need it).
  • Technology Tiering. Consumers will be asked to trade-up with their own money for superior technology. The three tiered formulary is a harbinger of things to come: the brand name over the generic, the low side effect drug over the higher side effect drug. Viagra and cosmetic surgery were just the beginning of this trend, but it will become more mainstream. While it’s harder to see how the technical content of inpatient care will be easily tiered : “Will that be the $1,000 or the $2,000 stent Mrs. Johnson?”, the trend is there. According to pharmaceutical companies, health plans and PBMs alike there has been remarkably little backlash against the tiered formulary. It is inherently American: you pay for the upgrade with cash or frequent flyer miles.

We are moving towards a system of floors and ceilings. We Americans want a floor below which no American falls, and the right to trade up with our own money. New economy entrepreneurs, innovative health insurers, and pharmaceutical executives are all salivating at the prospect of serving the affluent clients who can, and will, trade up to these new ceilings. But the new world of customized, consumerized and tiered healthcare will all unravel politically, economically, and morally if we do not guarantee the floor for all Americans. The business of healthcare must make a case for universality. Without it, the new consumerist nirvana can neither be created nor sustained.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This essay was published in the May/June 2001 Issue of the Health Forum Journal.

The Five Pillars of Leadership

Tuesday, March 6th, 2001

Health care is complex. It is full of professions, guilds, unions, and community stakeholders, all of which make leadership more difficult. How do you lead in such an environment? I offer, with some humility, my five pillars of leadership:

1. Distinguish between managing and leading.

This is by no means an original thought, but it is at the heart of the health care leadership problem. Health care at all levels, from presidential policy to bedside decisions, is over-managed and under-led. What’s the difference? You can do no better, in my view, than John Gardner’s definition in his 1990 classic On Leadership (Free Press, 1990). To paraphrase Gardner, leaders distinguish themselves from the general run of managers in at least six respects:

  • They think longer term.
  • They understand the relationship between their organization and the wider environment.
  • They reach and influence stakeholders beyond their own organization’s boundaries.
  • They put heavy emphasis on the intangibles of vision, values, and motivation, and they understand intuitively the non-rational and unconscious elements in both leading and following.
  • They have the political skill to cope with the conflicting requirements of multiple constituencies.
  • They think in terms of renewal and adaptation to an ever changing reality, not just sticking to the system.

2. Respect leadership as a political process.

Leading an organization is more like running a small country than managing a large store. Leadership is inherently political, which frustrates many promising managers who have been promoted because of high marks, good work performance, and self-righteous excellence. In a world of coalition building, compromise, and horse trading, these managers get frustrated, and many fail as leaders.

3. Understand the American leadership preference.

Americans like reluctant leaders with a casual, easygoing style much more than pushy, formal ones. They like Tom Hanks in Saving Private Ryan or Jimmy Stewart going to Washington, not Gordon Gekko of “greed is good” fame. This is why George W. ran his campaign with a “gee shucks” style and Al Gore took “business casual” to new lows.

4. Honor moral leadership.

A lot has been made of values-based leadership in recent years, but even Attila the Hun had values. When people say value-based leadership, they tend to be implying they have the right values, therefore their position should be followed. I prefer to think about the moral base of leadership. Is your position on the side of the angels (consult your own God here)? Is it life affirming? How would it look on the front page of The New York Times? Does it feel right in your gut? And most important, what would your mother say?

5. Lead the revolution.

Strategy guru Gary Hamel’s new book Leading the Revolution (Harvard Business School Press, 2000) is a must-read about the importance of breakthrough innovation in business strategy. Hamel in a nutshell, and in his own words:

“I found that most successful companies were following the polestar of some truly noble aspiration. What counted was not so much how they positioned themselves against longstanding rivals, but how creatively they used their core competencies to create entirely new markets.”

Health care desperately needs innovation, not just in process and tools, but in business and organizational design. We need leaders who can imagine better futures.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. A shorter version of this editorial was published in the March/April 2001 Issue of the Health Forum Journal.

The Rise and Fall and Rise of E-Health

Saturday, January 6th, 2001

E-Health, Baby. If Austin Powers was in the healthcare forecasting business, that would have been his clarion cry as the millennium dawned. The IPOs came fast and furious, anythinghealth.com was hot in the market, and the Industry Standard-the dot.com establishment trade magazine-declared breathlessly that “Net entrepreneurs are drooling over the prospect of fixing the nation’s healthcare system”. Watch out healthcare, you are about to be transformed.

Well, E-Health stocks are down an average of 70% this year (down an average of 90% from their all time highs) according to the leading investment analysts. Dr. Koop is on life support. Healtheon/WebMD is no longer the new, new thing. And disintermediators like Neoforma, who were going to change the rules of purchasing medical supplies are like whimpering puppies called to heel by the big old boys that run the medical supply game.

What happened? At a meeting in San Francisco in late 2000, a number of observers (myself included) gave their two cents worth on what happened. Larry Leisure, managing partner of Andersen Consulting’s dot.com Launch centers, and a 20 year healthcare industry veteran, points to the fact that many dot.com upstarts did not pay enough attention to the core questions: who is the customer and what will they pay you for? Leisure also points to the lack of industrial strength information technology and business systems, and a failure of the upstarts to cement meaningful strategic alliances with key industry players.

Chris Hester, a Principal with healthcare venture capital leader Acacia Venture Partners, points to four factors for the financial collapse:

  1. The strength of the legacy companies
  2. Technologies in search of a business model (companies focused more on new fangled products than on serving customer needs)
  3. Cheap capital created in the broader dot.com market euphoria leading to stupid decisions by entrepreneurs and fee-obsessed investment bankers
  4. Lack of true innovation in business models

Dr. Ed Fotsch, the CEO of Medem, the healthcare web-hosting company that is sponsored and owned by the leading medical specialty societies, points to the arrogance and naivete of dot.com opportunists who parachute into the industry without the vaguest clue of how healthcare is actually delivered.

They are all right. The new guys (the Second Curve) did not respect the legacy players in the industry (the First Curve). Think about it for one second. The American healthcare system is over a trillion dollars. That’s larger than the economy of a country like Italy. To argue you are going to reform Italy in one fell swoop is preposterous. The Pope, the mafia, Fiat, and the Italian government all might want a wee say in the matter.

The old players (health plans, doctors, hospitals, PBMs, GPOs, pharma companies and medical suppliers) simply didn’t trust the arrogant, new players and refused to just roll over. For example, health plans formed MedUnite to counter the threat of Healtheon. Group Purchasing Organizations like VHA and Premier and supply companies like Abbott, Baxter and J&J, each formed industry internet exchanges to challenge the new entrants like Neoforma.

Many of the E-health plays only worked on powerpoint. Few had any real paying customers, let alone any meaningful scale. Lots of us have gone on-line for healthcare information to be sure. Indeed my partners at Harris Interactive and Harvard in a recent survey conducted for our clients found that in 2000, 98 million Americans have been on-line for healthcare information up from 70 million in 1999. There is lots of use of the Internet for healthcare, but is it a business, and has it changed healthcare delivery? E-Health today is like Encyclopedia Brittanica in the 1950s: a nice place to look up information. We have become cyberchondriacs driving ourselves to distraction in the middle of the night, but we are not really getting what we want from e-health.

Consumers are more sophisticated. In other dimensions of e-commerce; buying a book, ordering theatre tickets, reserving tea at the Ritz in London, you can go on-line and do it. (Trust me I’ve done them all). Consumers expect that from e-commerce. Can you make an appointment with your doctor on-line, can you renew a prescription, e-mail your doctor, get a wheelchair? While there are businesses doing all of these they are not mainstream. And the reason is the new health economy has to connect to the old health economy. The future of e-health is not some cyber-doctor in Newfoundland delivering disembodied medical advice and dispensing pills. No, the consumer wants the services connected to local doctors and hospitals. Consumers want e-health delivered locally. And they are not getting it.

Indeed, the Harris/Harvard surveys show a significant (approximately 20%) decline in satisfaction amongst consumers with regard to various dimensions of e-health as the table below shows. (In fairness this is a declining share of a rising base of consumers which has moved from 70 million to 98 million). But, the conclusion is important. E-health has been hyped to the point that consumers (not unreasonably) expect it to deliver meaningful e-commerce services.

Table 1: Consumers use of E Health: Is The Bloom Off the Rose?

1999 2000 Change
The Internet helped in: % % %
Understanding of own health problems 73 56 -17
Managing personal health care overall 60 41 -19
Communications with doctor 51 29 -22
Compliance with treatments recommended by doctor 46 31 -15
Source: Strategic Health Perspectives, Harris Interactive/Harvard University, 2000

But, this is not to say that e-health is dead and over, quite the contrary. Rather, it is a classic case of what I called in my book “the Second Curve” Amara’s Law (named after my old boss Roy Amara who ran the Institute for the Future for more than 20 years). Amara’s law in a nutshell is that there is a natural human tendency to overestimate the impact of phenomenon in the short run and underestimate the impact in the long run.

E-health can be the platform for redesign of American healthcare delivery. It can be the new chassis as Kaiser CEO, Dr. David Lawrence says. But, it will require leadership, trust building and real innovation to bring the old health economy and the new health economy together.

Who will win? Perverse as it may seem, the best positioned of all are the group and staff model HMOs. Both Group Health and Kaiser are months away from very significant roll-outs of e-health capabilities that will allow consumers not only to make appointments and renew prescriptions but to interact with physicians electronically through clinical messaging systems. Similarly, Blue Shield of California (again a stalwart of the non-profit health plan world) has demonstrated capability for mass customization in the interaction with their enrollees, through mylifepath.com. (Although in surveys consumers are much less interested in the interaction with health plans compared to interaction with their providers). Similarly, web companies like Medem and Medscape/Medical Logic are run by doctors for doctors and they show promise in being able to provide practical tools that will allow doctors to communicate more effectively with patients.

The next round of e-health is about to begin. Doctors are starting to e-mail patients in significant numbers (we estimate about 10% of all doctors have some e-mail contact with patients today). A third of all doctors have websites and that number could exceed 50% very quickly if Medem and other are successful in their roll out over the next few months.

We must seize the e-health opportunity, not to make money for dot.commers and venture capitalists, but to change health care delivery. Forever.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This essay was published in the January/February 2001 Issue of the Health Forum Journal.