Healthcare: Horrors & Hope

1. Healthcare Horrors & HopeTom Peters/10.26.2004

2. 1. Premise.

3. “If one didn’t know better, one might think that hospitals set out to design systems that provide the most sophisticated technical care but deliver the worst possible experience to sick people.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

4. Golden American Age of Patient-centric, Genetics-driven Healthcare Looms!Current status: $1.3T+.30M-70M uninsured. 100K killed and 2M injured p.a. in hospitals. 85% treatments unproven. Cure depends on locale in which treated. 50% prescriptions do not work. 2X docs. 2X hospitals. IS primitive. Accountability & measurement nil. And … EVERYBODY’S MAD-AS-HELL AND FEELS POWERLESS: DOCS, PATIENTS, NURSES, INSURERS, EMPLOYERS, PHARMA & DEVICE COS, HOSPITAL ADMINISTRATORS AND STAFF.

5. 2. Consumerism(Patient-centric Healthcare Arrives)

6. Anne Busquet/ American ExpressNot: “Age of the Internet”Is: “Age of Customer Control”

7. Amen!“The Age of the NeverSatisfied Customer”Regis McKenna

8. “We expect consumers to move into a position of dominance in the early years of the new century.”Dean Coddington, Elizabeth Fischer, Keith Moore & Richard Clarke, Beyond Managed Care

9. “Parents, doctors, stockbrokers, even military leaders are starting to lose the authority they once had. There are all these roles premised on access to privileged information. … What we are witnessing is a collapse of that advantage, prestige and authority.”Michael Lewis, next

10. Today’s Healthcare “Consumer”:“skeptical and demanding”Source: Ian Morrison, Health Care in the New Millennium

11. “He shook me up. He put his hand on my shoulder, and simply said, ‘Old friend, you have got to take charge of your own medical care.’ ”Hamilton Jordan, No Such Thing as a Bad Day (on a conversation with a doctor pal, following Jordan’s cancer diagnosis)

12. “A seismic shift is underway in healthcare. The Internet is delivering vast knowledge and new choices to consumers—raising their expectations and, in many cases, handing them the controls. [Healthcare] consumers are driving radical, fundamental change.”Deloitte Research, “Winning the Loyalty of the eHealth Consumer”

13. “It may be the most far-reaching evolution of them all: the metamorphosis of passive patient into consumer – and well-informed, assertive consumer at that. The defining axiom of traditional medicine – ‘doctor’s orders’ is being turned on its head. These days it’s the patients who are armed, the doctors who must get wired to keep nimble.” “E-health is the new house call.”Richard Firstman, “Heal Thyself,” On Magazine

14. “Savior for the Sick”vs. “Partner for Good Health”Source: NPR

15. Consumer ImperativesChoiceControl (Self-care, Self-management)Shared Medical Decision-makingCustomer ServiceInformationBrandingSource: Institute for the Future

16. “The ‘curative model’ narrowly focuses on the goal of cure. … From many quarters comes evidence that the view of health should be expanded to encompass mental, social and spiritual well-being.”Institute for the Future

17. Determinants of HealthAccess to care: 10%Genetics: 20%Environment: 20%Health Behaviors: 50%Source: Institute for the Future

18. “Consumerism”: HMO backlash (e.g., plans with more choice).Alternative Medicine, Wellness & Prevention bias. Info availability (disease, health, docs, support groups, outcomes).Boomers (“I’m in charge!” Discretionary $$$$ to spend:cosmetic surgery, vision improvement, fertility, etc.).Self-care (chronic disease). High expectations (genetics, etc.) …

19. 3. Demographics: The BOOMERS Reach 60 in ’05!

20. “NOT ACTING THEIR AGE: As Baby Boomers Zoom into Retirement, Will America Ever Be the Same?”USN&WR Cover

21. Boomer World“From jogging to plastic surgery, from vegetarian diets to Viagra, they are fighting to preserve their youth and defy the effects of gravity.”M.W.C. Howgill, “Healthcare Consumerism, the Information Revolution and Branding”

22. “Pick up any copy of Glamouror Men’s Health, and you’ll see pages of advertisements encouraging readers to enlarge their breasts, retard baldness, correct their vision, improve their smile, or relieve stress through herbs, massage therapy, acupuncture—you name it.”Coddington, Fischer, Moore & Clarke, Beyond Managed Care

23. “Sixty Is the New Thirty”—Cover/AARP/11.03

24. 4. “Quality”: COULD IT TRULY BE THIS AWFUL?

25. “Quality of care is the problem, not managed care.”Institute of Medicine

26. “Without being disrespectful, I consider the U.S. healthcare delivery system the largest cottage industry in the world.There are virtually no performance measurements and no standards.Trying to measure performance … is the next revolution in healthcare.”Richard Huber, former CEO, Aetna

27. “A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments must be restructured according to evidence-based medical practice.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

28. “As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care.A surprising 85% of everyday medical treatments have never been scientifically validated.… For instance, when family practitioners in Washington were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

29. CDC 1998: 90,000 killed and 2,000,000 injuredfrom nosocomial [hospital-caused] drug errors & infections

30. 1,000,000“serious medication errors per year” … “illegible handwriting, misplaced decimal points, and missed drug interactions and allergies.”Source: Wall Street Journal / Institute of Medicine

31. Various studies: 1 in 3, 1 in 5, 1 in 7, 1 in 20 patients “harmed by treatment” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

32. HealthGrades/Denver: 195,000hospital deaths per year in the U.S., 2000-2002 = 390 full jumbos/747s in the drink per year. Comments: “This should give you pause when you go to the hospital.”—Dr. Kenneth Kizer, National Quality Forum.“There is little evidence that patient safety has improved in the last five years.”—Dr. Samantha CollierSource: Boston Globe/07.27.04

33. “This should give you pause when you go to the hospital.”“There is little evidence that patient safety has improved in the last five years.”

34. RAND (1998): 50%, appropriate preventive care. 60%, recommended treatment, per medical studies, for chronic conditions. 20%, chronic care treatment that is wrong. 30% acute care treatment that is wrong.

35. “Established state-of-the-art cancer care—about which there is no longer any debate—is erratically applied.”Source: Institute of Medicine’s National Cancer Policy Board

36. “In a disturbing 1991 study, 110 nurses of varying experience levels took a written test of their ability to calculate medication doses. Eight out of 10 made calculation mistakes at least 10% of the time, while four out of 10 made mistakes 30 % of the time.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

37. YE GADS!New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in administering drugs (1995 study) “average once every hospital admission.” “Lucian Leape, medicine’s leading expert on error, points out that many other industries—whether the task is manufacturing semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like those in hospitals.”—Complications, Atul Gawande

38. “In health care,geography is destiny.”Source: Dartmouth Medical School 1996 report

39. Geography Is Destiny“Often all one must do to acquire a disease is to enter a country where a disease is recognized—leaving the country will either curethe malady or turn it into something else.… Blood pressure considered treatably high in the United States might be considered normal in England; and the low blood pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the United States.”– Lynn Payer, Medicine & Culture

40. Geography Is DestinyE.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—prostatectomy. Rapid City SD 34X Elyria OH—breast-conserving surgery. VT, ME, IA: 3X differences in hysterectomy by age 70; 8X tonsillectomy; 4X prostatectomy (10X Baton Rouge vs. Binghampton). Breast cancer screening: 4X NE, FL, MI vs. SE, SW. (Source: various)

41. PARADOX: Many, many formal case reviews … failure to systematically/ systemically/ statistically look at and act on evidence.C.f., Complications, Atul Gawande

42. “Most physicians believe that diagnosis can’t be reduced to a set of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray? The radical implication of the Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes than it prevents.”—Atul Gawande, Complications

43. Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks. Hans Ohlin (50 yr old chief of coronary care, Univ of Lund/SW) : 620. Lars Edenbrandt’s software: 738.*Only this time it matters!

44. “Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural consequence of a system that systematically tracks neither its processes nor its outcomes, preferring to presume that good facilities, good intentions and good training lead automatically to good results. Providers remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the information age.”Michael Millenson, Demanding Medical Excellence

45. Genius Required?

46. Leapfrog Group:CPOE/Computerized Physician Order Entry*ICU staffing by trained intensivists**EHR/Evidence-based Hospital Referral****Duh I: Welcome to the computer age.**Duh II: How about using experts?***Duh III: If you do stuff a lotta times, you tend to get/be better.Source: HealthLeaders

47. The Benefits of …FOCUSED EXCELLENCE Shouldice/Hernia Repair: 30-45 min, 1% recurrence. Avg: 90 min, 10%-15% recurrence.Source: Complications, Atul Gawande

48. 5. The IS/Web REVOLUTION

49. “Some grocery stores have better technology than our hospitals and clinics.”—Tommy Thompson, HHS SecretarySource: Special Report on technology in healthcare, U.S. News & World Report (07.04)

50. “We’re in the Internet age, and the average patient can’t email their doctor.”Donald Berwick, Harvard Med School