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- It’s well known that despite lots of talk about evidence-based medicine, the U.S. healthcare system operates in an eminence-based model.
- Virtually the first thing I was taught as a new consultant was that one should always fix a process before automating it. If you get the process right, technology can turbocharge the impact.
Susannah Fox (Photo courtesy of HHS.gov)
When Susannah Fox was named as HHS’ new Chief Technology Officer, it was a surprise to many since she is an anthropology major and self-described “internet geologist," not technologist, by training. However, choosing her was a surprisingly perfect decision for the needs of the healthcare system. Whether conscious or not, it’s apparent she draws on the archaeology courses she mentions in her writing. Her predecessors, Todd Park and Bryan Sivak, did a terrific job of opening up government datasets and creating new models of innovation within the government. Fox is a natural pick to build off of that and extend into new areas.
A key reason healthcare's status quo is so terrible is that it’s an industry that operates in a tribal knowledge sharing model. It’s well known that despite lots of talk about evidence-based medicine, the U.S. healthcare system operates in an eminence-based model. That is, medical practice patterns are frequently based on who one trained under rather than the latest science has to offer. The great news is that every structural solution needed to have healthcare reach its full potential has been invented, proven and modestly scaled. It’s simply a matter of taking the mindset of an anthropologist/archaeologist to uncover the solution as Fox describes herself in Love Made Visible. The essence of the speaking I do publicly and inside companies is I'm a Johnny Appleseed of sharing what is over-achieving on Quadruple Aim objectives and how these approaches can position organizations to lead in the future. It's great that Fox is taking a similar approach in her sphere.
This past week, Fox spoke to this process in Invent Health: To Infinity and Beyond:
We will explore the shared challenges we face in sustaining human life in extreme environments here on Earth as well as in space: power-, volume-, and mass-constrained environments like rural Uganda, a hurricane-ravaged city in the U.S., polar expeditions, and the International Space Station.
You might ask what can we learn from Uganda. A lot it turns out. As healthcare addresses the catastrophic misalignment of resources in the population health era, one of the roles that is vital are community health workers. This is Dr. Prabhjot Singh’s focus as Vice Chairman of Medicine for Population Health and Director of the Arnhold Institute for the Mount Sinai Healthcare System — watch this video for great community health worker examples from abroad and how they can be applied in our own rural and urban settings.
Virtually the first thing I was taught as a new consultant was that one should always fix a process before automating it. If you get the process right, technology can turbocharge the impact. Unfortunately, healthcare is absolutely riddled with breaking this fundamental rule. That is, we constantly throw technology on top of a broken process and then are surprised that we don’t achieve the Quadruple Aim.
Old habits can be hard to break. It goes well beyond medical practice. In fact, I have argued that underlying virtually every facet of healthcare’s underperformance is healthcare purchasing. As I’ve spoken around the country, it’s clear that healthcare purchasers (private and public sector) are boiling mad and want to revolutionize health benefits purchasing and realize they’ve been passive for far too long. They are demanding that their benefits brokers step up their game. Pwc and others have pointed out that one-third to one-half of all healthcare spending is waste or doesn’t add value. Imagine any other area where that would be considered acceptable. I didn’t have to go on an archaeological dig to find employers spending 30-50% less per capita on health benefits. Paradoxically, the best way to slash healthcare spending is to improve health benefits.
Frustrated that more people didn’t know about these proven solutions and my belief that healthcare is the single greatest immediate threat to America, I created an open source project I dubbed the Health Rosetta. When the Rosetta Stone was rediscovered, it allowed scholars to decode previously indecipherable Egyptian hieroglyphics. For many, cracking healthcare’s code has been similarly challenging — thus the name. Fortunately, there is a broad array of physician entrepreneurs who have cracked the code. As Dr. Dave Sanders, CEO/Founder of ZOOM+ puts it, it’s possible to deliver twice the healthcare at half the cost and ten times the delight.
(Disclosure: As I've disclosed many times, the Health Rosetta is an open-source project that provides a reference model for how purchasers of healthcare should procure health services. In my role as managing partner of Healthfundr, a seed-stage venture fund, the Health Rosetta is the foundation of our investment thesis.)
In light of Fox’s time spent working with the Robert Wood Johnson Foundation (RWJF), she was undoubtedly exposed to the study of studies that RWJF commissioned to look at what drives health outcomes. The new industry taxonomy proposed in The Future Health Ecosystem Today report (slides 4-8) maps the drivers of health outcomes to the components of the Health Rosetta. The new taxonomy reflects the fact that 80% of outcomes are driven by non-clinical factors. Fox has played a central role in the best session every year at the Health 2.0 conference — the Unmentionables (great compilation here) that reflects so much of what drives health outcomes.
Although the Health Rosetta was conceived of less than a year ago to address the totality of what impacts health outcomes, the following are some examples of its growing usage:
- One of the largest business coalitions on health (regional groups of employers who convene on health benefits) is revolutionizing the structure of their annual conference around the Health Rosetta. They were the first but I’ve subsequently been asked to keynote several other business coalition meetings as well as speaking to legislators and state staffers focused on health. Benefits consultancies and TPAs are also leading the DIY Health Reform charge.
- The Health Rosetta is the basis for the investment thesis for a seed stage venture fund.
- The Health Rosetta approach has been used to solve healthcare’s most vexing problem, enabled a city to demonstrate that the best way to slash healthcare costs is to improve. benefits as well as teacher unions and management recognizing they should be on the same side of the table to slay the healthcare cost beast.
- A set of guiding principles that guide healthcare organizations on how to succeed in the new health ecosystem.
- The Health Rosetta is the call to action for a documentary that seeks to be the Super Size Me/An Inconvenient Truth for healthcare. With a world class film-making team (Oscar nominated, Peabody winning team) that can combine the seriousness and science of The C Word with the entertainment value of The Daily Show.
Despite this progress, the Health Rosetta has barely scratched the surface of how information on what is having the greatest impact on the Quadruple Aim. One could imagine the HHS Ideas initiative out of Fox’s department borrowing ideas from the Reproducibility Initiative to speed to dissemination of proven approaches to achieving the Quadruple Aim to overcome the historic 17 year gap between discovery and integration into clinical practice.
In a review of the quality of care among patients in the United States, only 60% of those with chronic conditions received recommended care. Studies of dissemination of evidence-based guidelines (aka, consensus statements) suggest that awareness varies widely across medical subspecialty, with awareness ranging from as low as 20% among cardiac surgeons to 90% to 95% among obstetricians. The dissemination gap for clinical research also has a time component. A review suggested that it took an average of 17 years for 14% of original (i.e., discovery) research to be integrated into physician practice. In general, dissemination of clinical guidelines using passive methods (e.g., publication of consensus statements in professional journals, mass mailings) has been ineffective, resulting in only small changes in the uptake of a new practice, and single-source prevention messages are generally ineffective.
The excerpt below from an interview with Fox outlines her view on how technology can be a Trojan Horse for culture change.
Susannah Fox, current Chief Technology Officer at HHS and former Pew researcher, knows it's a little odd that, as CTO, her background is in anthropology, not technology. But she thinks it's also illustrative of the role technology has to play in healthcare. “We’re living through this time right now where technology is a Trojan Horse for change,” Fox said yesterday at HxR in Boston. “We say technology, but we mean innovation. We say interoperability and open data, but we mean culture change. And this is why the HHS CTO is an anthropologist. I know about culture change. I know how difficult it is for everyone involved.”
I’m excited to see how Fox is able to translate this into lasting change for HHS and the industry as a whole. She had a big impact while leading Pew’s healthcare research but she now has an even bigger bullypulpit.
