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Sunday, February 26, 2006
You Are What You Measure - Part II

Google provided just 540 links to the phrase, but some of the highest ranking hits provided some good fodder. Leave it to the folks from MIT to provide a thoughtful treatise on the issue from 1998. Looking for something a little less heady? The Artful Manager penned a shorter article in 2003. So while I can't claim to be a Coin Dropper (see 10/9/2003 blog), at least I've got good company from similar thinkers.




Your Are What You Measure

I keep trying to distill some common truths about the work many of us are doing on transforming healthcare through information technology. A lot of the drivers for employing HIT come down to this: You are what You Measure. If you've read Freakonomics, you know that introducing measurements into a system can significantly affect that system and you tend to get changes that optimize those measures, but those measures may not necessarily get you what you want.

Measure test scores for kids a la No Child Left Behind and you get improved test scores, but not necessarily kids who are more prepared for success in life. You can also get more teacher cheating to ensure that the test scores are better - sometimes to the detriment of the kids themselves.

We're experiencing the same thing in healthcare. Right now, we get high-cost, inefficient, and only partly effective healthcare because we measure (and pay for) activities over outcomes and outcomes over process improvement. We should be targeting measures that ensure we are constantly working toward process improvement. That's the goal! More later.




Thursday, February 16, 2006
I've been thinking about the ultimate summary of everything I believe about what's wrong with healthcare and how to make it right. The answer?

Fog Kills

Did you just say "Ah" or "Huh"? Let me explain. Newt Gingrich is fond of pointing out that "Paper Kills." He's not wrong. He just doesn't tell the entire story. Paper (in other words, the lack of electronic health records) is just a part of the problem. The root problem is the fog of information. EHRs and even my personal mantra of "all electrons all the time" is part of the solution. But even if every bit of information in healthcare were managed electronically, it could simply lead to killing people much faster if not used properly.

The most electronically enabled part of healthcare is the means by which we pay for pharmacy claims (largely through pharmacy benefit managers). But PBMs benefit from the black box of the information they house within their walls and their contracts with both healthcare payers and pharmaceutical companies. While PBMs can, in theory, lead to lower costs and higher quality (a theory I would largely challenge in terms of their net effect), the part of their business model that is predicated upon the lack of transparency has the unintended consequence of hindering our collective ability to provide optimal care to patients.

PBMs aren't the only ones to blame here. Every sector of healthcare has contributed to the creation of information silos that lead to poor outcomes. Pharma companies have long benefited from the fog of information as they (for the moment anyway) have the upper hand on the gold standard, placebo-controlled, randomized trial data for their products and can outgun other attempts to counter their arguments. This point of leverage is quickly eroding as "evidence-based medicine" takes hold and payers' influence over prescribers increases. Doctors too. The misalignment of their incentives (they make more money when they practice bad medicine because they get paid for doing tasks and not for outcomes) is a major contributor to their active and passive resistance to pay for performance schemas.

The only solution is a systems-wide acknowledgement ("Hello. My name is John and I am a Fogaholic.") and a concerted, systemic transformation of healthcare. No single sector can afford to fall on the sword of transparency without all sectors committing to the same goal.

When omni-directional information flow in the healthcare marketplace (i.e., total transparency) is achieved, all sectors of healthcare will begin aligning with optimal health outcomes because any other behavior will become readily discoverable and will be ferreted out. Money will be made - but business drivers will wholly transform.

I'm out of time, so I can't elaborate further. Bottom line: Fog kills. So let's kill fog before it kills us all.