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MEDecision and the Agile Health Care Vendor

I would like to start by apologizing to MEDecision for this piece. Instead of writing only about the Patient-Centered “Medical Home” (PCMH) – a great idea, and one about which MEDecision has shown great insight as they move to provide PCMH implementation support – I have chosen to focus instead on the relationship between this idea and that of “business agility” in health care. In other words, I am writing about what I want to write about, not what they deserve to be heard about.


That said, the effort to make businesses of all stripes more agile provides an excellent perspective on PCMH, its likely effects, its evolution, and the pluses and minuses (mostly pluses) of MEDecision’s offerings and plans. If, instead of thinking of PCMH as the goal, process improvements as the effects, and MEDecision’s and other offerings as the means, we think of increased health care organization agility as the goal, overall improved outcomes and vendor ROI as the side-benefits, and the PCMH as the means, I believe that we get a clearer picture of how much PCMH really matters in the long run.


So let’s start by drawing the picture, very briefly: What is business agility? What is PCMH? What is MEDecision doing about PCMH? Then, let’s see just how much more agile, and more effective, PCMH will probably make health care – and what might be done even better.


Some of my conclusions may well surprise or shock you. Specifically, I suggest that at certain points less of an emphasis on quality will produce better outcomes for the customer/patient. Moreover, at certain points less of an emphasis on cutting costs will produce lower costs. And finally, I assert that the main value of PCMH in the long run is not that it puts more control in the hands of a single primary care physician or nurse practitioner, but rather that it is more capable of frequently interacting with and adapting to the needs of the customer/patient.


How could I possibly draw these conclusions? Let’s see.


What Is Business Agility?


I define business agility as the relative ability of an overall organization to handle change, and includes both reactive and proactive agility. Manifestations of agility include both increased speed and increased effectiveness of change. Side-effects of increased agility are lowered costs, lowered downside risks, increased upside risks (this is good!), increased revenues, increased margins, and increased customer satisfaction. These side-effects can occur over both the long term and the short term.


Initial data indicates that the most effective, and perhaps the only truly effective strategies allowing organizations to increase business agility are to:

 ·         Focus primarily on agility itself, and on costs, revenues, and margins only as secondary concerns. ·         Measure agility primarily as time to value, not as an ability to meet deadlines or time to market.·         Establish processes similar to those of agile software development.·         Scale agile efforts by making the scaling tools and resources fit the needs of the people driving the agile process, not by constraining those people according to the needs of the tools or the bottom line.

Key counter-intuitive findings about business agility strategies are:

 ·         New-product-development agility improvements typically have a greater positive effect (on costs, revenues, etc.) than those which enhance operational or disaster/risk management agility. Improvements in handling external changes have a greater positive effect than improvements in handling internal changes.
  • Reductions in downside risk can actually decrease agility and have a negative overall effect. Greater upside risk is almost always a good thing.
·         Improvements in proactive agility produce greater positive effects than improvements in reactive agility. However, agile organizations should focus on improving processes rather than on increasing the number of things processes anticipate.·         Scaling agile processes is doable. However, scaling them by “compromise” with existing non-agile processes is likely to inhibit, reduce or negate process and business agility improvements.

The PCMH, and MEDecision’s Take on IT

The term PCMH, frankly, is confusing. As it has evolved, it centers not around the patient or consumer (a user of health care services who may or may not be a patient at any one time), but around a central point of patient management, typically a “nurse practitioner” or “health care coordinator” operating from the point of view of the primary care physician for a consumer. Likewise, the “medical home” is not the consumer’s physical home, but a “virtual home” for each consumer’s patient processes, usually located physically and/or logistically within the health care system/infrastructure itself.


The key innovative concepts of the PCMH compared to present ways of handling things are:

 1.       It’s comprehensive (including all medical organizations that a patient interacts with, and all parts of the patient process)2.       It’s coordinated (i.e., there is one integrated process, rather than numerous isolated ones)3.       It’s continuous (not really, but it means to be and does bridge some of the gaps in previous processes)4.       It’s quality- and efficiency-driven (this is not explicit in current definitions, but is the likely outcome of today’s focus on improved quality and reduced costs)

In attempting to support implementation of the PCMH, MEDecision starts from a position of strength through various solutions. Its Alineo provides extensive support for real-world case (read: patient process) management by hospitals; Nexalign offers “decision support” for PCP-patient interactions; and InFrame provides cross-provider “health information exchanges” (HIEs). All three include collaboration tools that make the integration of separate processes into one coordinated process much more straightforward. All three ensure that insurance providers play their inescapable roles in the process. And today’s widespread implementation of MEDecision ensures that its current systems are collecting a large chunk of the quality and efficiency information that will be needed in, by, and to sustain the PCMH.


As you might expect, MEDecision’s immediate plans for the PCMH include extension of Alineo for use by a PCP’s “care coordinator” and development of “mini-HIEs” for the offices of PCPs. Further down the line, we might expect “telemedicine” for remote patient-PCP and patient-process interactions, “centers of excellence” for quality best practices, and better information-sharing with patients (and/or consumers) via the Web.

 Looking Through the Lens of Business Agility: Marketing Myopia

More than forty years ago, an article in Harvard Business Review titled “Marketing Myopia” introduced a fundamental tenet of good marketing: you must know what market you are really in; that is, you must know the biggest fit that you can make with your ultimate consumer’s present and future needs. Over the years, that tenet has taken many forms, from positioning cars as purveyors of feelings in the 1980s to ongoing one-to-one customer relationship management in the 1990s and leveraging social networking in the 2000s. Always, always, it has been a key component of business agility, because its success depends on the ability to continuously adapt to and anticipate consumers’ needs.


The “know your market” tenet also allows us to understand many of the key agility-related advantages – and potential flaws – of the PCMH. From this viewpoint, government and insurer are middlemen (if highly important middlemen); the real market is the vast majority of consumers who want the feeling embodied in the statement “I feel healthy [or can feel healthy]”. That does not at all mean that vendors should aim at deceiving consumers; in the long run, that never works. However, it does mean that the aim of vendors should be to constantly use consumer input to fine-tune their services to deliver both the objective reality and the subjective feeling of potential health to consumers, with government and insurers acting as tools for scaling agility, not reasons to shift focus from agility.


Looking at the PCMH concept, then, we find many attractive features for increasing agility and providing more agile processes. There is increased interaction with the consumer leading to increased personalized knowledge of the consumer (with privacy protections). There is coordination across organizations, plus the ability of one person to drive an individualized patient process, and adapt it to that patient’s needs. There is movement of process control, from people with rare interactions with a consumer, to people with somewhat more frequent interactions with the consumer. There is at least the beginning of the concept of “patient centric” processes.


There are also serious questions about the PCMH concept, centered around the idea of it being quality- and efficiency-driven. Business agility theory suggests that focusing on quality and efficiency rather than agility is self-defeating: it produces less quality and less efficiency than focusing on agility. How so? Consider how focusing on the speed of the patient process rather than its effectiveness, and assuming that effectiveness means an increased probability of the “right” surgery for an ailment rather than increased ability to “spiral in on” the right diagnosis and fine-tune it for evolving symptoms fails to put the patient process in the context of an overall lifetime consumer/health-system interaction. Consider also how inadequate such an approach  is in a constantly changing environment as the consumer and the society changes, and how such an approach focuses on tool and physician costs rather than supporting the ability of tools and physicians to better adapt to consumer needs.


These are all clear and present dangers of so-called quality-driven, efficiency-driven processes. The results of such approaches are more of what we have been seeing in the last forty years: dissatisfaction of every party in the process, cost squeezes that somehow increase expenses; process controls that eliminate touchy-feely services along with so-called inefficiencies, cookbook medicine that reduces the likelihood of immediate medical malpractice suits’ risks but increases the likelihood of poor outcomes that again increase the likelihood of malpractice suits; insurer and government regulations that continually lag medical knowledge and user needs; and usually inadequate, often adversarial problem resolution processes.


To correct these shortcomings, I believe it is necessary to go over the PCMH with a fine-tooth comb, aiming to make it agile rather than high-quality or cost-effective. For example, the “medical home” should be virtual, allowing a hand-off of central control to the hospital when the consumer is an in-patient, and to an in-home nurse or the patient him/herself for elderly consumers living in age-adapted homes. Use of outcome data should focus on consumer-driven changes in the service, the process, or process agility, not who did what wrong.  There should be greater focus on the use of up-to-date consumer data such as lifestyle decisions (private) that correlate with ailments, health worries, and “what if you face this situation?” scenarios. Annual checkups, specialist appointments, and hospital treatments should be all part of a strategy for continuous, dynamic interactions with the patient, with both personalized (diagnostic) and process-focused (procedures/surgeries) professionals fully aware of the patient’s historical context and able to adapt immediately via virtual access to other professionals in other parts of the process at any time. Over-provisioning to handle surges should be a necessary part of the cost structure, metrics and incentives on all sides should start with “time to value” rather than “outcome price/performance”, and virtualization (the ability to untether the process from any physical location) should be everywhere.

 Conclusions and Suggestions

Although business agility applied to health care would be nice, it is very unlikely that it will become pervasive in the next few years. After all, cutting-edge agile software development is still not really the norm in business IT, a decade after the introduction of the concept. Still, the PCMH is an excellent place to start, and MEDecision is in an excellent position to foster both PCMH and PCMH-driven agility right now – if some of the rough edges concerning quality and efficiency obsession can be smoothed away. Let me repeat my counter-intuitive conclusions:

 ·         Less emphasis on quality and more emphasis on adaptability in the PCMH patient process should lead to higher-quality outcomes;·         Less emphasis on cost-cutting by increased efficiency and more emphasis on more flexible patient processes should lower costs; ·         Less focus on the health care professional and more focus on frequent interactions with patients, even outside of the patient process, should allow PCMH to provide more satisfaction to both professionals and customers.

It must be noted that the biggest barrier to improved agility, oddly enough, is not the government, but the amazing ability of insurers to continually shoot themselves in the foot, business-wise. Here are two recent examples. First, the insurance industry should have known by 2007 from the examination of climate science that certain parts of Florida were or would become  difficult markets for home insurance in the not too distant future. It appears that only this year are insurers considering this possibility, and I doubt that they will do anything effective until 2012. The result: Five years of losses; easily predictable and preventable.


The second example, (altered to protect the innocent) is of a condition identified in the late 1980s, that under certain circumstances actually grants individuals a longer healthy lifespan. One insurance company, hearing the news of a diagnosis in the early 1990s, but using medical knowledge 10 years out of date to assess risk, refused further life insurance for a customer except at exorbitant prices, despite the fact that available data and family history confirmed that the customer had, if anything, fewer risks.


They have continued to do so for the past 20 years, as the customer approaches average male life span without serious problems, and in the process have cost themselves $1 million in additional life insurance sales, $300,000 in long-term care insurance premiums, and about $100,000 in wasted sales and customer-service costs – and the customer is extremely dissatisfied. Meanwhile, other insurance companies have typically followed the uninformed lead of the original insurance company, without even bothering to recheck with their medical experts.

 Let’s face it, insurers are so unagile and so focused on out-of-date risk assessments and costs, that they often wind up being more vulnerable to more downside risks, more costs, and less profits. Where should insurers look for advice on how to become more agile? Why, to software vendors, who are the leaders in implementing business agility, of course. Software vendors such as – well, such as MEDecision, who are themselves implementing agile new-product software development. Hmm.  Didn’t I say I wasn’t going to talk about MEDecision? Oh, well.


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YYCEB, (08/06/2013 05:34:43)

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Wayne Kernochan