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The Long March: The Right Stuff for a Health Model

2010/06/12

This is the first of several posts on realizing the vision in a sustainable community health model by aiming at transition and transformation.  Let’s start with some community basics.

[Edit note: added reference link for health expenditure data, and clarified the doctor phrases in the loans-versus-grants discussion of medical school costs.]

Pulling things together at the point of engagement with what’s in plain sight – that’s what we all do as we live day by day in our communities.  Looking at things in plain sight lets us study behaviors – the sciences of social behavior, communications and language behavior, culture as anthropological behavior, neurological resources behind it all.

Interestingly, the oldest social science, well before the fascination with formulae and numbers, is economics, initially political economy to reflect its focus on social behavior.  It’s derived from Greek oikos, “the house,” plus nomos, “rules.” This captures the notion that our cumulative decisions serve to frame our society’s shared public home.  Our lives are private, but not alone.

We have a lot to offer each other, and much of value to add by connecting our activities, if done with thought.  We can choose to add an intentionally aware element to the underlying systemic reality that informs our lives as human beings interacting with each other and our physical context.  Plainly speaking, we’re in this together.  We can choose to act to benefit our children, each other, and ourselves within that reality.

That’s the framework for today’s conversation about transitioning to a bodily and economically sustainable hospital and community health model – ultimately, regardless of detail, the only health model.  Consider the basics…

Resources need to be replaced.  It takes work to replace used resources.  A place will collapse if its usage exceeds its ability to work.  See “Collapse: How Societies Choose to Fail or Succeed,” by Jared Diamond.

Work has a pattern.  The pattern of work is that each step fits into the next step and the next, until it loops and repeats.  That is our systemic reality, and has been since we lived in caves and shared the work to survive.

This remains true for health delivery –

  • True for the economics of making, delivering, and using goods and services;
  • True for the interaction of health and the economy over time in an arc;
  • And the arc can deliver better healthy lives, or stuck points, or declining lives.

And ultimately, the arc will deliver only one sustainable result.  If split into shards of stuck or declining results, the edges will scrape away the capacity of the system to replace what is used, and given time and events, will not stand.

We live in the arc of the systemic reality we choose.  The arc is a large number of pieces and places that fit well together in a systemic reality, or that collapse sooner or later.

Let’s look at three key cycles and an action notion – health delivery, economic value, responses over time, and choosing our systemic reality by how we get there.

Let’s look at home base first – the overall systemic health delivery cycle over time.

We’ll start at the beginning.  So we’ll start with the preparation of the people who are the ones who practice medicine, without which there would be a void.  It requires years of work to be good with the tools and skills at hand.  And things go better if knowledge, skills, and training are viewed as lifetime team activities aimed at the person who needs the help.

Lifetime provider health delivery consists of three ongoing steps –

  • On your mark:  Continuous preparation
  • Get ready:         Coordinated action in the moment and over time
  • Go:                     Focus on the person being helped across all necessary skills

So let’s keep going…

How we handle “on your mark” affects everything else.  We continue as we begin, and we do better if we begin as we mean to continue.  This starts with the team nature of health work, including the road taken to fund the beginning.

This all points at resources; continuous learning; and team focus on people.  This also comes into focus on how we pay for startup and continuing prep –

  • Loans for preparation and continuous capacity building entail the vision of “doctors-versus-the-world,” where doctors need to extract dollars, else go broke.
  • Grants offer the vision of “doctors-within-the-world,” continuously offering best efforts to keep people healthy and dealing with real problems as they arise, not distracted by the need at some level to be searching for loan payback cash.

You think this is unrealistic?  Perhaps doctors aren’t influenced by loan-based career-choice incentives?  Let’s look at the record — A major case in point is the career choice starkly being made every day by doctors and dentists –

  • Primary care: Declining as a career choice
  • Specialist practice: Expanding as a career choice, and it’s for the money.

“Get ready” is all about what we choose to do.  Emphasis is the key — National Health Expenditure Data at Table 126 can be interpreted as over 75%+ of medical spend goes to chronic care and some 20% to acute care.  Stated another way, 75%+ of medical spend goes into co-morbidity cases.  This makes sense – people with chronic or acute conditions have systemic bodily issues that result in multiple problems presenting for attention.  Aging demographic cohorts don’t mean we can ignore the chronic and acute issue—they just add another layer to the reality that it’s both cheaper and more effective to prevent a problem than to let it burst, then try to pick up the pieces.

If we don’t re-think this tilt, then we face a crisis of overhead as dollars go into chronic and acute tools, facilities, and people, and as we starve the health-wellness process that reduces the growth rate in high-cost chronic and acute demand.  The challenge is managing a sustainable transition from an after-the-fact chronic and acute care culture, to a before-the-presentation prevention and wellness culture, by connecting public health, medical-dental-pharmacy, and demands from the ultimate bottom-line payers — employers and employees.  Stated another way, we need to ask about moving from demand for back-end catch-up care, toward more demand for front-end prevention and wellness.

In addition, the crisis of overhead makes critical the need to apply resources more efficiently, and knowledge more effectively, in operating complex facilities and practitioner teams.  This makes operationally essential, not merely nice-to-do, the smart use of cross-silo collaboration and technology to connect and align disciplines, participants, and budgets with fully patient-focused practice.

We can’t dance around the edge of this overhead beast.  We clearly can use resources better through collaboration across public health, medical, dental, and pharmacy practice, professional experience repository tools, and targeted technologies.  But all the tools and technologies can do nothing until the crisis of overhead first is acknowledged at all levels by all institutions and participants.

So we come to “Go” in the delivery cycle.  This is where work delivers value, if well designed and well executed.  Everything discussed here is needed to create sustainable value in the healthcare context.

Collaboration requires large-scale thinking and doing in small and large scenarios alike toward seeing the patient as the permanent center of a collaborative team.  It’s not that the patient is the expert – but all the experts do need to call on each other on the fly as they team to focus on the patient.  This takes teamwork thinking and practical technical tools to act like a team anchored across disciplines, distance, data, and time.  If this does not knit together, your system collapses.

If this seems unlikely, consider the cedars of Lebanon, and trees on Easter Island.  In both cases, each local area specialized, traded, did well, cut down trees, lost water, soil, health, and died.  It can happen again.  The analogy – our health systems drive the bodily ecology enabling our economy.

Again: hospitals, community health centers, and the medical-dental-pharmacy team are the trees that shelter the human energy that keeps us well and thus productive.  If we don’t work to cultivate a new collaboration across disciplines, distance, data, and time, hospital and community systems will collapse sooner or later, quickly or slowly, from a crisis of overhead, and we with them.

Here’s an example of a patient-focused team building tool—it’s a hospital-practitioner-hospital collaboration idea.  In a nutshell, Virtual Expert Clinics can create an extensible telemedicine asset (with low marginal cost after setup).  It enables wide-area provider collaboration and advice across public and community health, including primary, dental, pharmacy, and specialist practitioners.  You may think this a hodge-podge, but these practitioners all create input to what needs to be a patient-aimed experience repository with links across related presentations, diagnoses, prescriptions, actions taken, and step-by-step outcomes so all connected providers can focus smartly on any one patient every step of the way.

It’s ideas like virtual expert clinics connected with cross-linked experience repositories that bring out the real potential in Electronic Health Record systems.  Currently most EHR designs simply replicate current paper or data files as standalone electronic silos aimed in large measure at processing a welter of insurance systems and supporting individual hospital administrative systems—essentially non-medical, non-sharable, non-learning, non-action.  EHR designs need to do much more.

As a leverage for action, semantics thinker Phil Murray pointed out in this medical context that the need to do much more with EHR designs “walks in lockstep with the need to revisit how the work is done and by whom.  If the tools and materials that you introduce into a system affect how people work in basic, pervasive ways, [then] you have to revisit how tasks and roles are distributed.  This is one of the lessons of the Industrial Revolution.”

Let’s put this health discussion in a larger context.  Human energy and cash flow alike move in a self-sustaining cycle of create; transfer and apply; track and restore.  Health sector activities are no different.  They consume and transfer resources, generate value, and track the flow of funds and results.

The mission of healthcare is to sustain and preserve health, and upon need, to restore health as quickly and painlessly as possible, to the extent possible and without doing harm, with the resources at hand.  Therefore, the health sector, like any human activity, participates in a continuing cycle of seeking created value, transferring value by transforming it for various purposes, and paying attention to tracking value in varying ways.

Here’s an important point about tracking value — in any human activity, we need to keep score in order to know what works, what doesn’t, and what are the necessary trades to keep an overall mission moving forward.  And here’s a critical corollary — how we choose to pay attention to the flow of value directly affects the effectiveness of the value that we create and transfer.

We need to look at this cycle of value.  We’ll do so in a later post…

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