Square Foot Gardening

Over the past year, readers of my blog may have noticed my increased effort to eat locally by growing my own food in my home and community garden space.    As I plan the 2012 season, I'm making a list of the fruits and vegetables I'll want to eat, choosing the seeds from my favorite catalogs like the Kitazawa Seed Company, and thinking about how best to plant them in my raised beds.

Traditionally planting is done in long thin rows.   If you fertilize and water a bed with a few long thin rows, you get a great crop of weeds and less than a maximum yield of the fruits and vegetables you want per square foot of soil.

There has to be a more logical way, based on 3 dimensional thinking.

An innovative book, Square Foot Gardening by Mel Bartholomew logically examines the space and nutritional needs of various plants, enabling you to lay them out scientifically rather than randomly, per the graphic above.   The end result is higher yields, fewer weeds, less watering, less environmental impact, and less work.

This year, I'll be replacing a chunk of my front lawn with a series of 4x4 foot beds, filled with vegetables and flowers laid out via a Square Foot Gardening plan.

Not only will I have more fresh foods for the table, I'll have less grass to maintain, so I'm canceling my 'mow and blow' service and buying a push mower.

As I continue to strive for better personal sustainability and self sufficiency, Square Foot Gardening is one piece of the puzzle that adds to my efficiency.

The Healthcare Leader's Dilemma

At yesterday's IHI conference, I was asked to serve as a panelist for the CEO Summit.   We began the day with an inspirational case study from outside the healthcare industry - the transformation of US News and World report from a paper-based subscription model to a diverse web-centric family of products.

In 2007, it was clear that offering a paper-based magazine below cost, subsidized by advertising, was unsustainable.    Google's sale of targeted adds at low cost eliminated the business models of many print publications.

US News decided to become a specialized web resource offering news, college ranking, hospital ranking, and car ranking.   The advertising on each of these sites is highly targeted and actionable - when a customer clicks on a car, they are redirected  to a local car dealer's website.   At a time when web-based advertising may be $1.00 per 1000 clicks, US News and World report can charge $30.00 per 1000 clicks for qualified car buying customers.

This transition required layoffs, sale of the paper-based subscription customers to Time magazine, and a significant temporary reduction in sales in order to transition to an entirely new business model.  The future was unknown and the path to get there was risky.   In retrospect, it was exactly the right thing to do.

In healthcare, we are at a similar crossroads.

In an era of healthcare reform, we have three challenging choices

*Become a pioneer Accountable Care Organization (ACO) at a time when no one knows exactly what is necessary to succeed, but risks are minimized for early adopters

*Wait to become an ACO until the tools and technologies needed to succeed are better known, but risks for failure will be higher

*Continue to rely on fee for service income and hope healthcare care reform is delayed or deferred.   If healthcare reform proceeds, fee for service income will drop steadily over time leading to the slow demise of organizations which depend upon it.

Just as it was an educated guess to move US News and World Report to the internet in 2007, moving healthcare organizations to population health/wellness-focused accountable care organizations seems like  the right thing to do.  Yes, it may result in the downsizing of academic health centers and a reduction of some services like lab and radiology that are more expensive than community-based dedicated labs and imaging centers.   However, the future of healthcare looks a lot more promising for community hospitals and outsourced ancillaries than for academic health centers with high overhead costs.

Jim Reinertsen MD, Senior fellow of IHI and former CEO of CareGroup moderated a discussion of these ideas with Derek Feeley, Chief Executive of the National Health Service (NHS) in Scotland , George Kerwin Chief Executive Officer of President Bellin Health Systems, and me.

Our panel agreed with the model shown in the graphic above.   We're on a journey from episodic care to coordinated care to patient directed care.   We're moving from fee for service to bundled payments/capitation.   Our IT systems are evolving from segmented to integrated to community based.

Healthcare leaders must make a decision  Change now and risk moving too soon, incurring high costs.  Wait and risk moving too late, losing your competitive advantage.

In Boston, the healthcare marketplace is evolving so rapidly that our answer is clear - we must move to community-based coordinated care funded through bundled payments/capitation.  Implementing this transformation over the next few years will be a challenge for everyone, and along the way we need to ensure that the patient experience is not compromised.   We'll need leaders with a vision of the future, a guiding coalition of stakeholder supporters, a sense of urgency from the external environment, and a tolerance for risk.   I'm eager to be a part of the next phase in healthcare and look forward to learning from the people who make it happen.

A great discussion - thanks to IHI for the opportunity to participate and Jim Reinertsen for facilitating it.

Don Berwick Says Medicare is Wasteful

I was thrilled when Dr. Don Berwick took over as head of the Center for Medicare and Medicaid Services (CMS).  It was a politically charged appointment and the GOP wasn't standing for his type of medicine.  He would have never been confirmed and now he is saying goodbye to Washington.  Dr. Berwick admits Government is more complex than he realized and said "Government decisions result from the

The 2011 IHI Conference

Today I'm at the Institute for Healthcare Improvement Annual Forum in Orlando.

Every year, the keynote frames the state of healthcare in the US and the work ahead to make it better.

Maureen Bisognano delivered an energetic keynote that I would summarize as "join a community of motivated people and change the world"

She started with a refection on the book Connections by James Burke.   Innovation happens when people come together as teams and seize the right opportunities at the right time, often by accident.   Change can be surprising when different ideas combine, leading to a sum greater than the parts.  1+1 will equal 3.

Every year at the Annual Forum,  IHI brings together the healthcare community to share stories of improvement efforts with the hope that these lessons learned will spark innovation around the globe.  By listening to others stories, healthcare leaders will be inspired to envision a different, better future.

Maureen described IHI's goals as

*Realize Patient Centered Care and Outcomes

*Strengthen Healthcare Delivery Systems

*Drive the Triple Aim - improving the experience of care, improving the health of populations, and reducing per capita costs of health care

*Build Improvement Capability

She shared examples of people and organizations that have embraced these goals.

Christian Farman, an engineer and athlete from Jonkoping, Sweden developed glomerunephrtitis and the dialysis treatments were making him sick.  He worked with his nurse to design a program of self dialysis, putting him in control of his own health.  Today at the same Jonkoping dialysis center, 60% of patients self dialyze.  Christian returned to health, quit his engineering job, and became an RN.

Derek Feeley leads the National Health Service efforts in Scotland, where he has worked tirelessly to reduce central line infections and ventilator associated pneumonia.  Today, the central line infection rate in Scotland is zero - that's quality improvement for an entire country, not just a single healthcare system.

Intermountain Healthcare has reduced recovery times for ventilator dependent patients by encouraging early mobility - walking and exercising even before the ventilator is removed.

Kaiser has supported 6 million e-visits, using the web in creative ways for diagnosis, treatment, and followup.

At the Centers for Disease Control, Tom Frieden has championed the health impact pyramid - categorizing the interventions that have the greatest impact.   The base of the pyramid is socioeconomic factors followed by changing the context of decision making, long lasting protective interventions, clinical interventions, education and counseling.   The most effective way to treat chronic disease may not be a mediation or education, but eliminating homelessness and improving diet.

Maureen described the remarkable effort of a community group working to eliminate homelessness and improve health - www.100khomes.org

Socioeconomic factors are critically important when the economy is fragile.  Current 20% of the US has less than $1000 in savings.  50% has less than $5000.   At the same time
5% of population accounts for 50% of the cost of healthcare.

We live in an era of information and have an ability to share experiences ad collaborate on innovation more than ever before.

It's up to us to spread our stories and make a difference, working together as a community.

The Promise of Electronic Healthcare Records

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should frustrated that he was never confirmed.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care.   When I make decisions today, I reflect back on that intense training.  However, thousands of journal articles have been written since then, there's new evidence suggesting more effective treatment plans, and new therapies are available.   How do I ensure the just the right amount of care is delivered - neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders - just in time advice as to what my patients need.  Educational materials and literature can be embedded in the workflow for easy reference.  Population/panel health tools can identify those patients who need followup or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system - it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers.   Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport,  vocabulary, and content standards needed to support it.  Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume.   Some are so arcane that experts cannot agree on the interpretation.    If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests - building new functional or purchasing new products to meet every increasing numbers of rules.    We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.

Fraud

Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse.    Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense - Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance.   Don Berwick is a great supporter of the EHR's potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform - the federal 5 year plan to increase the use of electronic health records and healthcare information exchange - has broad bipartisan support.  

As Don Berwick returns to the private section, I'm hopeful that he'll turn his energy back to fixing the US healthcare system and that he'll be a tireless champion for electronic health records.

Tonight, I'm flying to the Institute for Healthcare Improvement Conference in Orlando to serve as faculty for the CEO summit.  I'll report on Maureen Bisognano's keynote tomorrow morning.

Cool Technology of the Week

Now that I'm a Macbook Air and iPhone 4S user, I find myself consuming multiple electrical outlets when I travel.    There's a solution - the Plugbug from Twelve South.

The Plugbug is a simple addition to your existing Macbook adapter that enables you to charge the Macbook and your iPad or iPhone simultaneously.

Twelve South has many other interesting Mac accessories to declutter your desktop and enhance your use of Apple devices.

Simple charging with one adapter for all your devices - that's cool!

Family Friday

I rarely take vacations and only celebrate major events (like birthdays) when schedules permit my family to assemble, since celebrations are more about the people present than the day of the event.

Thanksgiving weekend is one of those dates when everyone's celebration schedules coincide.  It's common to travel on Wednesday, to spend Thursday preparing a meal together, and to take Friday as a vacation day.

This year, I received fewer than 50 email on Friday, November 25, down from my usual daily count of 1000-1500 messages.

I believe that shopping during the holidays is a contact sport.   Traffic slows to crawl , tempers boil, and now there's even pepper spray to worry about.

Unless some twisted souls think of Black Friday as entertainment, I believe the concept should be replaced by Family Friday.

Talk a walk, go to the zoo, play Apples to Apples, talk about the future, have a Kazoo concert.

My experience with discounts, sales, and bargains is that they will be offered again or tempt you to buy something unnecessary.   A designer tie that's discounted 50% is no bargain if you have enough ties already.

I do not reserve my shopping for any particular day of the year or align it with any retailer's event.

Instead, I use Consumer Reports  to identify high value products - good quality at reasonable prices.   I buy few things, but always buy them to last, given that the real expense is churn - buying a poor quality item 10 times is generally more expensive than buying a good quality item once and keeping it for years.

My Prius has 120,000 miles on it and likely will be fine through 200,000 miles.   I'll replace it when its total cost of ownership exceeds the value of a replacement, regardless of the date on which that occurs.

I realize there are implications to discouraging a retail frenzy on Black Friday.  Sales imply profits which create jobs.

However, if we consider the big picture - that the US needs to move away from a consumer economy back to one in which we create innovative products and services that the world wants to buy, we'll not need Black Friday.

So let's spend time with our families next Black Friday and focus on innovation at work next Cyber Monday.

Our country and our sense of well being will be better for it.