On October 1 and 2 IBM held its second global Smarter Cities conference in New York City. I subsequently wrote about the excellent talk, Great Expectations for US Healthcare, given by Dr. Denis Cortese, CEO and President of the Mayo Clinic on the first day of the conference.
The next day, there were break-out discussions in six key areas relevant to building a smarter city: transportation, education, public safety, energy and utilities, government services and healthcare. I was co-moderator of the healthcare session, along with Dan Pelino, IBM’s General Manager of Healthcare and Life Sciences. Our panel of experts included Dr. Cortese; Chris Coburn - Executive Director of Innovations at the Cleveland Clinic; Dr. Ronald Paulus - Chief Technology and Innovation Officer at the Geisinger Health System; and Dr. Armando Ahued Ortega - Health Secretary of Mexico City. Let me summarize their practical and concrete remarks.
Dr. Denis Cortese spoke first and talked about the three key steps needed to implement the kind of comprehensive healthcare transformation that he outlined in his presentation the day before. “My personal feeling is that everything starts from vision,” he said and added: “It is very difficult to create a shared vision where people have a picture of where we want to end up . . . It takes a long time for people to get to a point that they actually realize the vision was their own idea . . . it’s the only way you get people to really buy in, you have to say it over and over and over again, engage with them.”
“The first couple of times they sit back and say, this is the craziest idea I ever heard. The third time they say, gosh, he's talking about that again. I've heard it before. The fifth time, yes, he's still at it. And what is he really talking about? The seventh or eighth time they sort of say, yes, I know all that. And the eighth time they say he's stealing my idea.”
Once there is a consensus on the vision, comes the hardest part of the task - developing a shared reality. This is when people being to realize how far away they are from the vision, how big the gaps are, how monumental the job is. “The shared reality part is frankly where our country is today. We're just . . . we're coming through the grief process of denying all the shared reality that is really out there.”
The last step involves coming up with a strategy to implement the compelling vision arrived at in the first step, given the reality and the gaps discovered in the second step. If the goal is providing high value, patient-centric healthcare, you now need to begin breaking down the problem into manageable tasks. In anything as complex as healthcare, you need to design and architect a system that is implementable, flexible and adaptable to the myriads of requirements you will have to support now and in the future.
Chris Coburn spoke next about the innovation work he leads at the Cleveland Clinic. He talked about the close link between a smarter healthcare system and a smarter city. The Cleveland Clinic is very focused on the overall health of the community around it, not just on individual patients. For example, the Clinic has just announced that anyone can walk up to any of their facilities throughout northeastern Ohio and receive an H1N1 vaccine as soon as the supplies arrive.
He talked about the economic impact of the Clinic on the city of Cleveland, a large, mature metropolitan area of about 2.5 million people. Cleveland once had a large manufacturing base that does not exist any more. Today, the Cleveland Clinic is by far the largest employer in the region, as well as the largest Ohio-based employer in the state. The Cleveland Clinic is thus playing a central role not just in delivering healthcare, but also in the very economic transformation of the region around it, much as is the case with UPMC in Pittsburgh and the Mayo Clinic in Minnesota.
Coburn discussed the close links between healthcare innovation and job creation. “We have created 32 companies that just in the last seven years have been spun off from the Cleveland Clinic . . . three quarters of those companies are headquartered in the City of Cleveland . . . our vision is we want to see our campus ringed with companies and a free intellectual exchange that creates a churn that produces ever more innovation whether it's in the provision of care, or conceiving of new devices, or drugs or diagnostics. So that's the environment we have committed ourselves to, and these companies are a means for achieving it.”
The next speaker was Dr. Ron Paulus of the Geisinger Health System. Geisinger serves 2.5 million people in rural Pennsylvania. “We are what one might describe as a quintessential integrated delivery system: 800 doctors, three hospitals, a myriad of ambulatory care facilities and centers. We have almost 50 clinics spread out across 20,000 square miles where sometimes the cows outnumber the people . . . We really are a major part of their lives for many of them, and it gives us a unique vantage point to reflect from. In general, demographically, that population is older, fatter, poorer, sicker and less mobile than most of the United States.”
Geisinger is implementing a four part strategy. The first, Dr. Paulus said, is a system of care that makes sense, and rewards and focuses on the right things. It includes innovative concepts like the medical home, where the central Geisinger health plan funds care management nurses that live in the remote rural practices, know the local people well and assist the primary care workers. The central health plan and the primary care workers in the practice work closely as a team, using predictive analytics and other advanced technologies to anticipate and try to prevent problems. If agreed-upon efficiency, quality and savings metrics are achieved, half the money goest back to the practice.
Dr. Paulus talked about the importance of managing chronic disease, which their analysis has shown is a key driver for productivity and quality improvements. Many of their patients suffer from multiple such chronic illnesses, as many as eight in some cases. It is very important that when doctors treat patients, they see all the relevant information about the various chronic diseases in the screen in front of them, so they can provide the right overall care.
The second part of their strategy involves changing the incentives, so that when people do need hospital procedures, good outcomes are rewarded and there are no perverse financial incentives for adding additional, unnecessary treatments. Geisinger has created a bundled payment approach for acute episodic illnesses, with one price for the entire bundle from the time the decision is made for a surgery until 90 days after the acute intervention. If things go wrong, it is the responsibility of the Geisinger system, not the patient, who is charged one price with no incremental payments.
The third part of Geisinger’s strategy involves carefully managing the handoffs in care, such as transitions from ambulatory care to in-patient and back, or from in-patient to nursing home. They know that these handoffs can result in high risk for low quality and inefficiencies. To do them effectively, they require an integrated information system so that every new team treating the patient knows what has happened before. In addition, Geisinger uses sophisticated analytics to try to predict the risks of re-admission and then apply the appropriate additional resources to lower those risks.
Last but not least in Geisinger’s strategy is to actively engage patients with their care. Dr. Paulus said that 40 percent of all the expenditures in healthcare are driven by patient behaviors, 30 percent is a result of genetics, and the rest is a result of the actual quality of the healthcare provided. Consequently, engaging the consumers and patients in their own care is fundamental to achieving better outcomes.
They do this by sharing with the patient all the information available to the physicians about their risks for say, a heart attack or stroke over the next ten years. They show the patients the various options for lowering those risks, from changing their eating habits to taking different medicines. Then, in close collaboration with the physicians and other providers, the patients select the treatments they are most comfortable following.
What about patients that do not want to do anything? Dr. Paulus said: “We want to know not because we want to give up but because if that patient is walking in there saying, “I don't want to do anything,” we need to know. In my view . . . people in healthcare talk a lot about “noncompliance.” I don't think there is such a thing as noncompliance. I just think there are people who comply with a different plan of care than the one we give them.”
The last member of our panel, Dr. Armando Ahued Ortega, gave a dramatic accounting of the events in Mexico City in April of 2009 as they encountered the H1N1 virus. Last spring, Dr. Ahued and his colleagues started noticing the appearance of a new kind of virus in Mexico City. At the beginning they did not have the slightest idea what they were facing. Was it just a mutation of the normal seasonal flu, or something much more serious, like the so called Spanish Flu that killed tens of millions of people around the world in 1918?
On April 17, Mexico City declared a national epidemiological condition as the number of cases kept increasing. On April 23 they knew that this was not just a variation of the seasonal flu, but some kind of new virus, they had not seen before and knew nothing about. As the number of cases kept increasing, they declared an epidemic and closed all the schools. But that did not help because the kids, while no longer in school, were still congregating with each other in other places
As they saw the number of patients and deaths continuing to climb, the Mexico City authorities had to make a critical decision whether to close down the city, despite the huge economic impact such a decision would have. But, they had no choice. On April 27 the decision was made to close practically the whole city, including restaurants, bars, movies, theaters, churches and sports arenas.
This was a very difficult, and expensive, decision to implement in a metropolitan area of around 20 million people. For the next two weeks, Mexico City was at a virtual standstill. Fortunately, after a few days, the number of flu cases and deaths began to rapidly drop. The city started to reopen around May 6 as conditions returned to near normal.
To quickly informe people of the status of the epidemic, Mexico City has developed a four color alert system that tells the population what is happening and what actions need to be taken. The system uses highly sophisticated information gathering, analysis and predictions so they can quickly figure out what is going on and then alert everyone in the city using the appropriate color, from green - signifying that there is no health emergency, to dark orange, - meaning that there is a high emergency and all group activities are restricted, as was the case for nearly two weeks this past spring. Finally, there is red, to be used in extreme emergencies when the city is in quarantine and all economic activities are suspende .
Experts around the world have praised Mexico's swift, transparent and decisive actions to mitigate the spread of influenza, as well as the help they subsequently provided other countries by sharing all the available information about the H1N1 virus. The general consensus is that it was the right thing to do given the risk and uncertainty the city officials were facing in the early days of the pandemic. In a talk given this past July, Dr. Margaret Chan, Director General of the World Health Organization said:
“Mexico was the first country to experience a widespread outbreak. Mexico bore the brunt of these consequences at a time when the new virus had not yet been identified and nothing was known about the disease it causes. Mexico gave the world an early warning, and it also gave the world a model of rapid and transparent reporting, aggressive control measures, and generous sharing of data and samples.”The excellent talks by our four panelists clearly illustrated the vast challenges and complexities involved in designing effective healthcare systems. The scope is enormous, ranging from how to best treat large numbers of individual patients in a highly personalized way, to how to best deal with the health issues of entire communities, cities and nations. But, our panel also showed how fascinating this area is, especially now that we have all kinds of new information and technologies, as well as new ways of thinking about the problems which will hopefully enable us to develop increasingly smarter healthcare systems.