A Japanese Starbucks Model for Healthcare Quality

I'm flying back from Japan to the US today and on the way I purchased a vegan (soy) Green Tea Latte from Starbucks.   I relish the Japanese version of this beverage because it is unsweetened (even a bit bitter), since the Japanese typically do not like sugary foods and drinks.   As I ordered the beverage, the clerk behind the counter handed me a special quality control token to ensure I would not receive any dairy products.

Although my choice of soy is related to a lifestyle choice and not a medical condition such as a milk allergy, Starbucks in Japan wants to ensure "zero defects" in the delivery of soy-based drinks to eliminate accidental allergic reactions.

When my beverage was ready, I handed the soy "safety token" (pictured above) to the Starbucks barista who then double checked my receipt to identify that the beverage ordered was the beverage delivered.

Imagine how this Six Sigma/LEAN approach could be applied in hospitals.   Upon admission, patients could be given a token (a bar coded wrist band, a laminated card, an upload to their smartphone etc) that is handed to every caregiver before a medication is administered.   The patient and caregiver verify accuracy together so that right drug is given to the right patient at the right time.

I realize that many hospitals including BIDMC have implemented or are planning bedside medication verification (bar code the patient, bar code the medication, bar code the caregiver and scan/scan/scan before a medication is given) and electronic medication administration records (close the loop between orders and actual administration by charting medications administered electronically), so we're headed in the right direction.  Meaningful Use Stage 2 and 3 will likely include several new medication safety workflow requirements.

However, in the meantime, if Starbucks can use laminated cards to prevent allergies and ensure zero defects in my Green Latte, hospitals should feel inspired to examine their medication workflows and think about simple solutions to do the same for our care delivery processes.

The Japanese Congress and the Global Health Forum

This week,  I traveled to Japan as part of a 'US-Japan health care policy dialogue' a partnership between the Center for Strategic and International Studies (CSIS), a Washington-based foreign policy institute, and the Health and Global Policy Institute (HGPI), based in Tokyo.  This collaboration between American and Japanese experts focused on critical areas of innovation and reform in the health sectors of both Japan and the United States - initially payment systems and healthcare IT.  Over the next 6 months, we'll complete an analysis with actionable policy recommendations.

As part of the effort, I provided testimony to the Japanese Congress (Diet) and joined an all day Global Health Forum organized by the Health and Global Policy Institute (HGPI), a leading Japanese think tank.

The Congressional experience was interesting.  Japan has the longest lifespan of any country in the world, has comprehensive healthcare coverage for all citizens, and has very low healthcare costs - less than half the US expenditure per person per year.   It's challenging to highlight lessons learned from the US which has highly variable quality, high cost, and 40 million uninsured.

Luckily, the Japanese agreed that Healthcare IT is to be embraced for quality/safety/efficiency, cost reduction, and job creation.

I described the US Healthcare IT program as guided by 5 goals

*Improving quality, safety, efficiency, and reducing health disparities
*Engage patients and families in their health care
*Improve care coordination
*Improve population and public health
*Ensure adequate privacy and security protections for personal health information

achieved with 5 tactics

* Policy (Health Information Technology Policy Committee)
Certification and Standards (Health Information Technology Standards Committee)
Privacy and Security Tiger Team
Regional Extension Centers and Health Information Exchanges ($2 billion)
Incentives to adopt and achieve “Meaningful Use of Electronic Health Records” ($21 billion)

The Japanese legislators asked great questions about the role of genomics, the role of telemedicine, and the potential for job creation.   I remain optimistic that the Japanese will consider their own healthcare IT stimulus program.

The all day Global Health Forum included several important key points:

In Japan over the past 50 years, the economy has shifted from agricultural to industrial, from rural to urban, and from communities bonded together to often impersonal cities without support systems of the family and friends.   Many Japanese die alone and do not have the eldercare they need.

25% of Japanese are over 65 and over the next 50 years, the problem will get worse, such that 2 working age individuals will be paying for the care of 1 retirement age individual.   The Japanese birth rate is 1.3, so the Japanese population will fall rapidly over the next 50 years, reducing the workforce and tax base.   Immigration is very limited in Japan, so diminishing Japanese and limited foreign workers with result in a crisis of public funding for healthcare .    The Japanese will try to balance cost, quality, and healthcare access with available funds, but even now there is gap between the funds received from workers and the funds paid out to pay for the care of the elderly.

IT can provide some mitigation of the problem.   Japan has one of the best wired and wireless networks in the world.   These can be leveraged to create virtual communities/social networks of carers as well as support homecare including telemedicine and remote monitoring.   IT can provide data for population health and care coordination.

At present Japan has many policies which discourage the use of the public internet for healthcare, data exchange, and homecare. Changing policy/regulation and providing incentives to move care to the home is an important next step.  Focusing on wellness and day to day life rather than just treatment of disease is also an important tactic.    Japan describes this as a transition from "medical policymaking"  to a "health policymaking".

The session on healthcare IT included my presentation, a presentation from Dr. Akiyama of Tokyo University, and a presentation from Intel.

Many of themes in Japanese society apply to the US.   Our aging baby boomers will require more care than the Medicare system can afford.    Secretary Sebelius has said that 1/3 of US healthcare is redundant and unnecessary.      I look forward to continued exchange of ideas between the US and Japanese.  We are meeting again this July at CSIS in Washington.

Cool Technology of the Week

As I prepared for my trip to Japan this week, I had the opportunity to discuss Japan's overall IT strategy with several corporate, government, and academic leaders.

The three major goals include

1.  Providing enhanced IT services to citizens
2.  Using IT to enhance communities
3.  Create new markets and businesses

National healthcare IT goals include creating a national framework supporting personal health records,  enhancing telemedicine capabilities, and building population health measurement resources to enhance quality, safety, and efficiency.

Here's a full text report and an executive summary.   It's great reading and provides powerful insight into the elements of IT and Healthcare IT that are important to Japanese Society.

To me, supplementing our own policy and technology thinking by reading the plans from other countries is always very cool.

Regression to the Mean

You may have heard about the Sports Illustrated Effect, the notion that people who appear on the cover of the magazine are likely to experience bad luck, failure, or a career spiral.

Over the 30 years of my own professional life, I've watched many colleagues become famous, receive significant publicity, then fail to live up to the impossible expectations implied by their fame.   They regress to the mean.  Nature seems to favor symmetry.   Things that rise slowly tend to decline slowly.  Things that rise rapidly tend to drop rapidly.

Fame is usually a consequence (good or bad) of invention, innovation and accomplishment.   Fame itself is generally not what motivates a person to accomplish their feats.   An Olympic athlete is usually inspired because of a highly competitive spirit.    An inventor is usually inspired because he/she believes there is a better way.    Fame that is the consequence of a feat can affect future behavior.    It can become an intoxicant and motivate someone to strive for accomplishments that keep the fame coming.

I've thought about my own brushes with fame.

When I was 18 and started at Stanford, I realized that my scholarships would only cover the first year of tuition.   I visited the Stanford Law library, read the US tax code and wrote software for the Kaypro, Osborne 1, and CP/M computers that calculated taxes.  The software shipping from my dorm room generated enough income to start a small company.  When the PC was introduced, we were the first to provide such software to small businesses seeking to compute their tax obligations.   By the time I was 19, I moved into the home of Frederick Terman, former Provost of Stanford, and the professor who first encouraged William Hewlett and David Packard to build audio oscillators and form a new company called HP.  The story of a 19 year old running a software company and living in the basement of founder of HP was newsworthy at the time.    I did interviews with Dan Rather, Larry King, and NHK TV Japan.

The company grew during my medical and graduate school years, but as technology evolved it did not innovate to take advantage of new platforms, graphical user interfaces, or emerging networks.   I sold the company when I began my residency.   It eventually closed.

By the time it closed,  I was learning to build clinical systems and worked during residency to  develop a hospital-wide knowledge base for policies/ procedures/protocols, an on-line medical record, a quality control system, and several systems for medical education.    I achieved local fame when the County of Los Angeles voted me the County Employee of the Month, the first time it was given to a physician.

I left residency and began practice at Beth Israel Hospital while doing post doctoral work at MIT, writing a thesis about using the web to securely exchange medical records.   In 1997, using the web was considered risky, unreliable, and insecure, but the recent merger of Beth Israel and Deaconess needed a quick win, so "CareWeb" was born.   I became CIO.

In 1999, Dr. Tom Delbanco and others had the idea that patients should be able to access their own records electronically.   My team created Patientsite.   We were credited with inventing one of the first personal health records.

And the list goes on -  the 2002 network outage, early regional healthcare information exchange, harmonizing standards, creating a private cloud for health care records, and achieving hospital certification in the meaningful use process.

The interesting conclusion of all of this is that in every case, the fame was temporary, and very soon followed by regression to the mean - a stellar performance or innovation became typical/average/mundane.

It's nearly impossible to remain at the front of the race forever -eventually someone stronger, faster, or more nimble will displace you.

In my case, I stopped thinking about my own reputation and fame about 1998, recognizing that every episode of fame is followed by a decline into anonymity - the Sports Illustrated effect.   What's lasting are great organizations and teams that are constantly reinventing themselves - changing the race they are running.

Steve Jobs said "we're as good as our last product" and he's right.

If you focus on creating great organizations, which consistently achieve discrete episodes of fame but continuously innovate so that those episodes of rise and fall actually look like a continuous series of peaks, then you can beat regression to the mean.

The organizations in which I work will last for generations.  Their reputations transcend anything I will ever do personally.   My role is to champion, support, and publicize a few key innovations every year that will keep the organizations highly visible.  That visibility will attract smart people and retain the best employees who want to work for a place on a rising trajectory.   If I can transform the rise of fame and regression to the mean into a trend that feels like one organizational strength after another, I'll declare victory.

A Mission to Japan

This week I'm in Tokyo meeting with Japanese government officials (legislative and executive branch) to share lessons learned from  US Healthcare IT stimulus efforts and plans for healthcare reform, including the IT implications.

Although the Japanese are much healthier than Americans, they have their own healthcare challenges.    Japan has an aging society, a low birth rate, disparities of care across income levels, and rising costs.   Since reimbursement is largely via government funded programs, the imbalance of those seeking care and those paying into the system will create a crisis of rising costs over the next decade.   Here's a news story from the Japan Times that illustrates the problem.

Hospitals are typically not connected to the internet because of privacy concerns.   Data is rarely shared with patients or among providers because of misalignment of incentives.   IT adoption among hospitals is highly variable.

My message to the Japanese is that  healthcare IT is one tactic that can help.

Using electronic health records provides a foundation for quality measurement, decision support, and exchange of healthcare data for coordination of care.     Incentives need to be realigned to focus on quality and outcomes rather than fees for services rendered.   Privacy policy needs to be formulated that protects confidentiality and patient preferences but also enables collection and exchange of data that fosters wellness by encouraging the right care at the right time.    The excellent work in error reduction that has permeated Japanese industry needs to be applied to healthcare.    At present, Lean/Six Sigma approaches have not been applied widely to hospital care.

A healthcare IT Stimulus program for Japan, incorporating lessons learned from ARRA/HITECH is a good first step.   By deploying technology and creating policy in parallel, the Japanese can innovate in healthcare, reducing costs and improving quality.

The Current State of US Health Information Exchange

As Massachusetts formulates its health information exchange goals, priorities, and business models, we've been curious about plans in other states.   We've reviewed case studies, blogs, and academic papers.   However, there has not been a collected summary of the national HIE experience we could reference.

That resource is now available.

ONC released 3 valuable documents that I highly recommend to all HIE stakeholders.

A summary of the current state of HIEs in the US.

A detailed description of the models/approaches used .

Case studies of each model .

As states implement live data exchange in support of Meaningful Use stage 1,2 and 3 over the next 5 years, there will be remarkable lessons learned by comparing the relative success of these models.  It's unlikely that one size will fit all, but successes and failures will lead us to a parsimony of models which sustainably connect every provider, patient and payer in the country.

The February HIT Standards Committee meeting

The February HIT Standards Committee meeting included an overview of our work assignments from from the HIT Policy Committee, the kickoff of new Quality Workgroup initiatives, a preview of upcoming medical device hearings, an update on the Direct Project,  and a rich discussion of the Standards and Interoperability Framework (S&I Framework) including what it is and what it isn't.

The meeting began with an update from Dixie Baker about the charge from the HIT Policy Committee to assist with digital certificate standardization.    In general, the role of the HIT Standards Committee in the S&I Framework is to specify the desirable characteristics of harmonized standards, do environmental scans of existing standards to provide feedback on harmonization work,  and evaluate work products of the S&I Framework, such as the Direct Project.     As a next step, Dixie's Privacy and Security Workgroup will specify the desirable characteristics of X.509 certificates that are needed for the Direct project and the Nationwide Health Information Network.

The Privacy and Security Workgroup has also been charged by the Policy Committee to assist with Provider Directory standards. Walter Suarez will lead that initiative, doing an environmental scan of existing approaches (HL7, IHE, OMG, LDAP, state HIE's, commercial solutions) and developing a list of desirable characteristics as input to the S&I Framework process.

Thomas Tsang from ONC, provided this overview of the work on quality measures to be done in support of Meaningful Use Stage 2.   The Quality Workgroup will be assigned this work.  We'll name a new workgroup chair to guide the process and we'll add additional experts to the workgroup.   As part of quality measure development, we will evaluate the burden of capturing quality data imposed on providers, workflow, and software implementers.  Exclusionary criteria that have little impact on measure performance can be especially burdensome.   The Standards Committee made a consensus statement that exclusionary criteria should be optional, implemented at the discretion of provider organizations if they feel such criteria are significant to their measure computations.   In the case of BIDMC, almost all exclusionary criteria create burden without benefit and we would elect not to include them in our calculations.

Liz Johnson described the March 28 Clinical Operations Workgroup Medical Device Hearing which will include a patient/consumer panel, a provider panel, an Interoperability/ Data Integration panel, a Data Accuracy/Integrity panel, a  Device Security/Data Security Panel and a Universal Device Identification panel.   The Clinical Operations Workgroup will also take on the charge from the Policy Committee to assist with demographic code sets and an evaluation of patient matching strategies.

Arien Malec provided an update on Direct, including a list of the existing live installations (here's an overview of BIDMC's Direct experience).  He'll return at the March 29 Standards Committee meeting to describe lessons learned from production implementations.

Doug Fridsma provided an update on the S&I Framework, including a rich discussion of several concerns about it.

The Standards Committee members recommended

*incorporating experienced experts and their lessons learned in the process

*involving the Standards Committee at the beginning of the process to specify the desirable characteristics of harmonized standards for each project.   Since the first 3 S&I framework projects are related to clinical summaries, labs, and transfers of care, the Clinical Operations Workgroup will be the initial liaison to the S&I process.

*performing a mid project review via the Standards Committee to ensure the work is on track and achieving the desired outcome

*evaluating the deliverables at the end of the process via the Standards Committee to determine if goals have been met

*leveraging the NIEM process without adopting NIEM XML or discarding current standards that are already part of meaningful use stage 1

*engaging the Implementation Workgroup to evaluate NIST test scripts and gather feedback from early pilots to reduce the certification burden

*incorporating vocabularies and code sets recommended by the Standards Committee, leveraging work done to date instead of reinventing what is already in progress

Doug's slides support all of these points, promising to involve the HIT Standards Committee in the S&I Framework to a  much greater extent than in the past.

We summarized the day with plans for the next meeting and a recap of charges to each workgroup

Whole Committee
  On March 29 we'll review the timeline and milestones along the path to the Certification and Standards NPRM for Stage 2 to develop a project plan for April to October
  On March 29, we'll do a final review of the Direct project based on live implementations

Quality Workgroup
  Name a new chair
  Provide eMeasures oversight
  Educate the entire Committee about the information models used to generate quality measures

Privacy/Security Workgroup
  Policy Committee's Certificate charge
  Policy Committee's Provider Directory charge

Clinical Operations Workgroup
   Device hearing
   Policy Committee's Patient matching/demographics code set charge
   Liaison to S&I Framework for Lab, Transfers of Care, and CDA Cleanup efforts

Implementation Workgroup
   Liaison to NIST for test script review and refinement

I look forward to the work ahead!