We went for a walk yesterday. Griffin carried a stick.

Humans go for walks to “clear our minds” or “get in touch with nature.”  Dogs already have clear minds. For them, the freedom of a walking trail without security of a leash or the familiarity of a daily walking route can, it seems, be confusing.  “What am I here for?”  “Where are we going?”  “What’s our goal?”  Griffin (see photo above) promptly found himself purpose in the form of a big stick to carry.  “Now I feel so much better,” he seemed to say.

Clay Christensen writes and speaks about this,  and as we ambled through the Albany Pine Bush yesterday, I realized that Griffin explicitly understood that having clarity of purpose was far better than the freedom (and ambiguity) that the vastness of opportunity offered.  The task was now clear: find a big stick and safely deliver it back to the car.  In choosing this task, he became focused, engaged and (dare I anthropomorphize?) proud.  He looked up at us as if to say “see what I have? Do you approve?  Is it big enough?”  Rather than randomly running through the woods, criss-crossing the path, distracted by new scents, distant chipmunks and blowing leaves, he maintained a steady trot with head and tail held high, and a steady gaze straight ahead, maintaining his placement squarely and very intentionally in the middle of the path.

And just as Griffin seems to seek the freedom of ambiguity yet ultimately prefer the comfort of structure, humans thread this needle every day and seem have different levels of comfort with the unknown.

An aside:

Teaching family medicine residents and medical students last week, I was struck by this variability.  Some young physicians are perfectly happy to know that they don’t know the cause of a patient’s condition, so long as it is either resolved or not caused by something ominous.  Indeed, more than one-third of the time that patients seek medical assistance,  physicians are unable to ascribe a clear diagnosis.  As I expressed to the first-year medical student last Tuesday, “if you’re not comfortable with uncertainty – don’t pursue a career in family medicine. You’ll be better off in a subspecialty like ophthalmology.”  This was not meant to deprecate subspecialists, but to recognize that the people who choose subspecialties are generally less comfortable with the unknown or unknowable.  While my counsel was expressed to her, I was also advocating for her future patients.  There is nothing worse than a primary care provider who needs to know the right answer to every question.  Indeed, cascades of testing and intervention are emotionally, physically and financially harmful.  In many cases, a physician’s personal discomfort with uncertainty is the cause of the cascades that are so common that we accept them as an unfortunate but immaleable reality. The key, therefore, is to match individuals with the work they will do most comfortably.  Some dogs would roam the forest happily.  Griffin is a dog who prefers to carry a stick.  Some physicians are comfortable with uncertainty, so will be very comfortable in primary care, while others would suffer as primary care providers, ordering too many tests, advising too many interventions, and as a byproduct of all of this, putting their patients in harm’s way. Perhaps this is the tip of a different iceberg: just as Malcom Gladwell has questioned whether we’re choosing the right law students, is it possible that we’re choosing the wrong medical students for careers in primary care?

Physicians are just a subset of humanity.  Non physicians express this variability too.  The motto of my undergraduate alma mater, Hampshire College, is “Non Satis Scire.” Translated:  “To know is not enough.” Hampshire attracts students who are less focused on getting an A+ and therefore demonstrating what they know (indeed – there are no grades at Hampshire).  Rather, Hampshire’s focus is on helping students solve problems.  This prepared me incredibly well for a career as a family physician.

Which problems should Hampshire graduates solve?  This question may be at the core of Hampshire’s rebirth.  Some have argued that Hampshire should choose an identity (social justice, environmental science, computer gaming) and focus its resources on being the best at one thing.  But Hampshire has decided instead to venture forward with confidence and – yes – uncertainty.  This will prepare its current and future students well for what lies ahead in life.  They’ll find their own stick, perhaps after a bit of chipmunk chasing.  Life isn’t a race.

I found my stick, which aligns well with the specialty that chose me, family medicine: help others achieve optimal health and happiness.

What’s yours?

Like many businesses, our organization has problems to solve.  We have good people, products and processes but on occasion we decide that we need more than we have.  Our Chief Strategy Officer sometimes reminds me that my vision for our achievements might not be aligned with our capacity.  Perhaps this is the role of the CEO – to think a bit bigger than we are.  But that’s another blog post.  The point here is that we may need help sometimes.

When businesses develop strategies to solve problems, they generally adopt one of a handful of approaches:

• Hire a person or people
• Buy something
• Build something
• Try something (pilot / proof-of-concept or POC)
• Partner with another organization

RFPs are generally reserved for big projects and evoke thoughts of 45 page .pdf documents with tens of questions and months-long processes of evaluation.

For the record, we never do POCs or pilots.  We do projects, and all projects have phases of implementation.  Phase 1 is always first, and while we can certainly kill a project at any stage, “phase 1” sends an implicit message that we’re optimistic that there will be a second phase and others thereafter.  We’re not ambivalent about moving ahead with anything.  “POC” and “pilot” send a message of ambivalence.

There’s an opportunity for organizations to use a process that’s smaller than a big RFP and bigger than a solution-focused decision.  It’s the Mini-RFP.  We’ve done a handful of these and they’ve worked incredibly well. The whole thing takes 3 weeks.

Here’s how to do it

1. Week 1
   1. Day 1:
      1. Define your problem. This isn’t as easy as you think.  We use a modified A3 strategy approach.  You can use any approach, but be careful not to be looking for faster horses.
      2. Pick an online survey tool you like.  SurveyGizmo, Google Forms, Microsoft Forms, or Survey Monkey are all just fine.
      3. Write a set of questions that capture basic business demographics.  You can re-use these every time.  Name, URL, contact info, how long in business, etc.
      4. Write a short statement about the problem you’re trying to solve.  Work hard to make sure that it aligns with step 1 and do your best to avoid describing a product that you’ve seen that you think solves your problem.
      5. Write a set of questions that asks respondents how they would propose to solve your problem:  what do they have (people? product(s) , processes?) that solves your problem.  It’s important to avoid leading questions that align with a particular solution you may subconsciously have in mind.
      6. Show the RFP to a friend.  Ideally, give them edit rights and ideally this person doesn’t have first-hand knowledge of the problem you’re trying to solve.  They need to be able to look at this fresh with a “beginner’s mind.”  Tell them to go ahead and fix whatever they think needs fixing in the form.  No permission required.  No time (or need) for “suggested edits.”  You’ll be pleased and surprised (and humbled) to see how your initial prose made assumptions that you didn’t see.  Let your friend fix them and leave your ego behind.
      7. Add  “Brown M & M” questions.  While the rationale here is a bit different from what Van Halen did, the idea is the same.  You need to know if the respondents are paying attention and have sufficient domain knowledge.  We use these questions when we post upwork jobs and they work incredibly well to weed out folks who respond by pasting in paragraphs from other proposals.  Instant proposal rejection is what you’re looking to enable here.  Be creative here and have fun.  One recent RFP asked if BTC, XLM, ETH or neo4J had a role in the project. We asked submitters to avoid googling for an answer.  This question was asking two sets of questions:  a) How much of a nerd are you?  (We wanted nerds) – Do you know what BlockChain is?  – Do you know the difference  between cryptocurrency and a graph database? b) Do you know that blockchain probably plays no role in this project?  (But a graph database might.)  Successful respondents get the right answer in 30 seconds because they have domain knowledge.  These should be easy questions for the right people and impossible questions for the wrong ones.  (If you use the right survey tool – you can see how long they took between questions.)  This isn’t a tortoise/hare issue.  Perhaps we’ll need to have a chat with Malcom about that.  We love tortoises.
   2. Give them 3 – 4 days to reply.  We often launch on monday.  Close Friday.
2. Week 2  Process, review, rank, have phone calls with a few of them to get a better sense of who the people are and if you are likely to work well with them.  Pick a “winner” by Friday.
3. Week 3
   1. Monday.  Send the lead applicant a contract. Negotiate rapidly.  Lawyers may slow you down.  The more you have templated ahead of time – the better – so at least on your side, there are no legal delays.
   2. Friday.  Execute the agreement.  Go!

When we announced a few weeks ago that our IPA had executed our first contract, I found myself explaining what an IPA is and what it does.  An IPA is a business entity that assists multiple independent organizations to contract with managed care organizations (health plans).  But it’s uncommon (unheard of?) for an IPA to work with organizations that are not physicians.  We even had to update the Wikipedia entry on IPA to clarify that physicians aren’t the only ones who can create or join an IPA.

Where we are now

We have over thirty organizations participating in the IPA.
We have two executed agreements with health plans, and expect this to grow.
We have a technology platform that connects our community.

Where we are going (and why)

I re-read the 1990’s coffee-table Book “who moved my cheese?” recently, and am now reminded of the simple (yet complicated) lessons therein. The book provides a framework for how we respond to change. A key message is that change will always happen.  If we resist it, we will become angry, fearful and confused.  If we embrace it, we’ll find new opportunities and flourish.  Our IPA is focused on helping organizations embrace (rather than fear) the change that is happening.  These changes will, we hope, help us improve the health of hundreds of thousands of people in New York and beyond.  Our plan is to continue to build relationships on both sides of this work: growing the breadth and scope of the organizations who join the IPA, and growing the number of health plans with whom we partner.

While the metaphor of a well-oiled machine is overused, I reflect that the mechanics of Alliance are running well – primarily because we have learned to anticipate and embrace change.  Indeed, our comfort with change has become our secret sauce.  The challenges of early days of start-up disorganization and growth are well behind us, and while we’ll never be perfect, and the start-up of an IPA is non-trivial, our team is working together to do our best to serve our community.  I am honored and privileged to work with such a dedicated and talented group of people.

Our (amazing) team at Alliance for Better Health is planning an event in June.  The purpose is to bring together people in our community who are using the Healthy Together platform, celebrate the community’s accomplishments, and strengthen the connections so that we can find greater success in the future.

I offered a thought this morning that perhaps this isn’t a conference, but an unconference.  I wikipedia-ed (it’s a verb, yes?) the term, hyperlinked it in my email and (after sending) went back to read the wikipedia entry.  It’s accurate and (I now know) expresses a long history of unconferences.  What surprised me is that one of the first unconferences in “modern” times was in 2003 and .. I was there!  Despite a dead website, I was able to find someone’s notes on my session @ bloggercon.  It’s funny how the world is a circle.

To me, the core of an unconference is not unlike the core of a nontraditional post-secondary education, and the core of a person-centered approach to health:  the goals are defined by the people who participate rather than by the people “in charge.”

• Students at Hampshire College define their educational goals.  Faculty, staff, technical and physical resources are all there to support (and – yes – guide) students on their path.
• Attendees at an unconference listen, learn, and direct the course of a community of co-participants.  Organizers are there to support (and-yes-guide) but the goals of the unconference are expressed by the participants, not dictated by the organizers.
• People served by medical care providers, behavioral health providers, and social care providers are the ones who define their own goals.  Words like “noncompliant” or even “non-adherent” become laughably out of place once we understand who is really in charge.  We physicians are (I suspect) the worst violators of this imbalance of power, as we’ve been educated to “write orders” and “define treatment plans.”  Only recently have we discovered shared decision-making.  If “primum non nocere” is really our oath, perhaps we should converge it with “non satis scire” and offer some humility: audire ad primum non nocere, quod non satis sit scire.  (“Listen to do no harm, it is not enough to know.”)

A few days ago, I wrote about the convergence that seemed to be happening at Hampshire College.

Yesterday, the President and another Board member resigned.  There was cheering and excitement at Hampshire, facebook, and Slack.

Why was there cheering?  Because the President charted a course for Hampshire that many in the community felt was (so far) an unnecessary last resort.  Is it possible that Hampshire would some day need to partner with another institution?  Yes.  It’s possible – after other options are deemed infeasible.  The problem here is that the community doesn’t understand how/that Miriam Nelson sufficiently researched all other options, and how she deemed them infeasible so early in her tenure @ Hampshire.

She believed that what she was doing was good for Hampshire. Some members of our community were angry at her, and I understand that anger, but I never felt it myself.  In the same way, I don’t feel happy that she decided to step down.  This has been terribly difficult for her, I’m sure.

But this is bigger than her, or any one person (or even any group of people).  Now is the time to pull together, and her departure gives us that opportunity.  The convergence I described on Wednesday continues.  On campus, several members of the Alumni Advisory Group (AAG) joined the re-envisioning Hampshire Coalition meeting. It was eye-opening for me.  These folks are serious, dedicated, and working hard to make sure that all voices are heard.  That’s super important.

And now the really hard work is ahead of us.  Here’s a rough map of all of the groups that will need to converge on what the future Hampshire College looks like, how we fund it, and how we get there from here.  

The AAG met all day @ Hampshire yesterday, and we’ll do so most of today as well.  We’re a diverse team – with members from each of Hampshire’s decades, expertise in many domains, and (most important) diverse perspectives on how to interpret what’s going on at Hampshire and how to respond.  We are a microcosm of the Hampshire alumni community, and what’s fantastic is that we trust each other.  Since change moves at the speed of trust, this has enabled us to move swiftly toward consensus on many issues, and enables us to bridge connections between others through the growth of such a trust network.  Much more to do, and we wouldn’t be able to accomplish any of this without our canine member @Griffin.

Wow.  It’s been too long since I’ve posted here.  I’ve been busy with my day job .. and writing elsewhere (some recent stuff referenced here). 

Now .. the topic of today:

Hampshire College. It’s not in a good spot.  Lots of history here .. and here .. and here.  Yesterday’s Boston Globe article is a short summary of the most recent events.

Why do I care?  Because – well – Hampshire is an amazing place, doing amazing things, and the world needs it to be there forever.  I spent three years there as a student, and one year there (a few years later) teaching and working in the admissions office. I did well there, and that empowered me to do well in medical school, residency, as a faculty member and Associate Dean at Albany Medical College, etc.  What I mean when I say “did well” isn’t that I got good grades, because (for those of you who don’t know) .. Hampshire has no grades.  “Doing well”  in this context means (I think) that we move forward, have positive impact on the world, find happiness and share that positive  impact with others as widely as possible.  Hampshire discovered and fostered the “growth mindset” and reinforced it long before Carol Dweck started talking / writing about it. 

This is a blog. It’s not a facebook post, slack channel or shared strategic plan. It’s a set of observations that I’m choosing to share with you. I’m just one person. F83, P10 (That’s Hampshire-Speak for:  “I entered Hampshire in the Fall of 1983 and I’m the parent of a former Hampshire student who entered in 2010.”  I give money to Hampshire. I’m ready to give more. Some of my guiding principles for this post, and how I’ve tried to approach the current challenge:

1. Be generous and assume best intentions. Decisions have been made. We don’t really know all of what went into the decisions. We may learn more. We may ultimately disagree with these decisions. But I refuse to judge anyone as evil, malignant, incompetent, etc. These words just don’t help. I’m going to assume that everyone here has the best interest of Hampshire in mind.
2. Engage with shared success as the primary goal. It’s not important to be right. It’s important to listen, learn, seek understanding, and find the right path forward together.
3. The Hampshire College that has been is not the Hampshire College that will be. Product-market fit has not been achieved in recent years. Many people will be unhappy with the changes that will need to happen.  These changes include:
   1. Administration / administrative overhead will need to change – ideally get (much) leaner.
   2. Hampshire’s educational offering(s) will need to better align with the wants/needs of incoming students. Yes. This means that some faculty won’t stay. We may love them as humans, but if they teach stuff that not enough students want to learn – isn’t it our responsibility to invest in different mentors? This concept may threaten long standing principles of academia.  So be it.  This is Hampshire.  We should do the right thing, not necessarily the traditional thing.
4. There are some elephants (frogs?) in the room. Resolving them is going to need to be part of any cogent solution.
   1. The discount rate has been going up (and up). Translated: students who can pay full tuition are a small minority of incoming classes. The College therefore operates at a loss.  While many colleges operate this way, Hampshire’s investments (endowment) doesn’t generate sufficient revenue to cover this gap.  The endowment itself is restricted.  It can’t be used to cover operating expense. Hampshire needs to attract more students so that it can be more selective, and (at the same time) bring in more students who can pay full tuition.  
   2. Some students have not done well at Hampshire. Ideally, Hampshire is the right place for students who will excel in an educational environment that offers more freedom in exchange for more responsibility. Accepting students who can’t manage this responsibility puts everyone in a tough spot: students struggle, retention is reduced, cost is increased (see above – as discount rate goes up), and demands on faculty are enhanced (causing the College to hire support staff – and pressure to reduce faculty: student ratio). The Hampshire of the future will need to attract the students who will excel at Hampshire. Hampshire needs to be the positive choice for those who will flourish, rather than the negative choice for those who don’t fit in elsewhere.  It’s always been hard for Hampshire to find these students, but I believe that this is the only way for Hampshire to be sustainable long-term:  get more selective.  Focus on excellent applicants, not just unique ones.

What’s next?

I feel convergence in the air. There is growing consensus that an independent option may very well be viable. I see three key vectors – the latter two of which are converging:

1. Strategic partner. I’m assuming that this is the University of Massachusetts. Sure – other options are being considered, but UMass makes more sense than any other institution. Much to work out here, and there is huge risk that the true identity/purpose of Hampshire is lost in a merger (acquisition) with (by) UMass.  
2. The Re-envisioning project. Watch this as a good overview. It’s good. Lots of thinking and selfless collaboration went into this initiative.
3. Hampshire2020. This project is smaller and quieter. Here’s their v1 deck. I hear there’s a V2 deck but I’ve not (yet) seen it. 

You’ll notice that the re-envisioning project and Hampshire2020 are similar. They’re both great starts, but both of them rely on huge fundraising efforts to save the day right now.  (See http://give.savehampshire.org for links to fundraising activities, and also support Davis Bates as he takes a 17 mile fundraising walk this week).  Without a massive influx of $$, Hampshire can’t stay open in a form that will be attractive to the two populations most important to its future:

1. Donors. Humans, alumni (also humans!), foundations, and corporations. People give money for many reasons – but “save this dying ___” is rarely a compelling message. Rather – “make an investment in this ___ so that the world will be a better place” is generally much more successful.  A healthy Hampshire College is indeed something that many could / would support.  We need a clear, believable plan.  My former boss (yes – that’s another story) Vinod Khosla offers what I think is the best overview of how to pitch an investor.  We need to pitch investors with a strong story about how we’re going to make the world better with a new Hampshire College. 
   
   
2. Students. Hundreds of thousands of these people select higher education options every year.  Yes, there are fewer of them now, but there are still plenty of them, and plenty who would love Hampshire.  Simply put, they are the customer.  They make these choices based on a set of factors that are important to them, just like the customer at a restaurant, car dealership or online bookstore. I would argue that we need a core set of product management principles to be applied here.  I’ve seen very little of this in the re-envisioning project – and only tips of this iceberg in Hampshire2020’s proposal.  What are the market requirements? What resources do we have available to meet these requirements? How is our product differentiated?  I’m concerned that we’re a bit too focused on the asset we have (the current faculty, curriculum, structure) and not the one we need.  There’s compelling evidence (enrollment is the key metric, of course) that our current product isn’t well aligned with the market.

Doing – not just talking.

I’m ready to dig in. I’m ready to join the coalition of great people working toward an independent Hampshire. I’m ready to invest my time and my money in this initiative.   What do I mean by “this initiative?”  I mean the coalescence of re-envisioning Hampshire and Hampshire2020.  I’m ready to bring what I’ve learned in ~ 30 years of work in health, health care, information technology, investing and government to help us converge.  Because we must.

… all rumored to be in the mix to acquire athenahealth.

Nope.

Why not?

a) Apple doesn’t do “verticals.” It’s that easy. Apple sells products that anyone could buy. A teacher, a doctor, my mom. Sure – they have sold high-end workstations that video editors can use, but so could a hobbyist filmmaker. Likelihood of Apple buying athenahealth ~ .01%

b) Cerner Nah. While (yes) they have an aging client-server ambulatory EHR that needs to be replaced by a multi-tenant SaaS product (like the one athenahealth has built), they have too much on their plate right now with DoD and VA and the (incomplete) integration of Siemens customers. Likelihood of Cerner buying athenahealth ~ 1%

c) Microsoft. Like Apple, it’s uncommon for MSFT to go “vertical.” They have tried it. (Who remembers the Health Solutions Group?) But the tension between a strong product-focused company that meets the needs of many market segments, and a company that deeply understands the business problems of health (and health care) is too great. The driving force of MSFT, like Apple, is to sell infrastructure to care delivery organizations. Owning a product that competes with their key channel partners would alienate the partners – driving them to AMZN, GOOG and APPL. Likelihood of Microsoft buying athenahealth ~ 2%

d) Salesforce. I’d love to see this. But it’s still unlikely. athenahealth has built a product, and they (now) have defined a path to pivot the product into a platform. This is the right thing to do. Salesforce “gets” platform better than everyone (aside from, perhaps, Amazon). But Salesforce has struggled with health care. They’ve declared n times in recent years that they are “in” to really disrupt health care, and with the evolution of Health Cloud, and their acquisition of MuleSoft, they have clearly made some investments here, but the EHR is not the “ERP of healthcare” as they think it is. (Salesforce’s success in other markets has been that they dovetail with – rather than replace – the ERP systems to create value and improve efficiencies.)) The way that Salesforce interacts with the market is unfamiliar (and uncomfortable) to most care delivery organizations. So if Salesforce “gets” platform, and athenahealth wants to be a platform when it matures, could these two combine It’s the most likely of the three, but I still see the cultures of the two companies (I know them both well) as very different, and not quite compatible.Likelihood of Salesforce buying athenahealth ~ 10%

Others?

a) Phillips. ?They have enough $$, are getting into population health, have IoT “last mile” business alignment, and understand the need to migrate from FFS to value on a global scale.

b) Roper / Strata. Yeh – you didn’t think of this one! Roper owns Strata Decision. Cost accounting fits well into the revenue cycle roots of athenahealth. Strata is getting deeper into the role that clinical activity (and deviations from best practice) plays in cost. Dan Michelson (Strata CEO) understands the EHR market incredibly well.

c) Amazon. Platform. ABC. 1492. I’ll say no more. If you don’t know what I’m talking about, LMGTFY.

d) Value Act.? Elliott’s not the only big player that may have interest in owning this real estate.

e) IBM. Yup. Could happen. They have made significant investments in health (and health care). Unlikely but possible.

I’m sure there are more. This will be interesting. athenahealth has a vibrant culture, fantastic people, a strong, devoted customer base, and an active developer community. Remember:? this is a revenue cycle company, not an EHR company. The EHR is a new game they’re playing. It’s an important one, but Todd and Jonathan got into this business with the goal of solving business problems for their customers. That vision remains. It turns out that a healthier population is (or should be) good for business, and an EHR is (for now) part of that picture. But as the needs of the market evolve, athenahealth will evolve. They’ve demonstrated this well, and this agility is what will cause them to be successful in the long-term.

“Innovation” is a provocative word.

For some, it invokes an eye-roll of disdain: “why can’t we just get our work done?” They rhetorically ask. Sometimes, the way we are doing things is just fine. Why distract ourselves with new variants of people, processes, or products just for the sake of doing something new?

These folks have a point. Sometimes we just need to do what needs doing.

And sometimes the way we’ve been doing it (or even what we’ve been doing) isn’t optimal. “There must be a better way” says … someone.

That someone is the innovator. The eye-rolls The innovator is used to eye-rolls. And much worse. Indeed, the innovator has been maligned, undermined, threatened, disciplined, and even fired for thinking about the better way.

There’s a good reason for this. Most innovations fail.? When innovators dream of a better way, and therefore spend time thinking, working on projects that may or may not bear fruit, “wasting” valuable time and money so that they can .. what “Improve things!?”

Such is the healthy tension, especially in the industry known as “health care.” Lives are at stake, so we must innovate with extraordinary care, lest we harm people. There is good reason for this.

Or is there?

When I was in medical school, I was “spoken to” because I asked questions of a professor who was teaching us tradition that was (even at the time) not supported by science. Thirty years later, what he was teaching us is now well-known to be inappropriate. The path to better care (and more health) is asking whether there is a better way:? questioning the assumption that “we’ve got it right” and always challenging ourselves to look at things from another perspective.

As CEO of Alliance for Better Health, I serve with an amazing team of people who are helping our community change. We are a New York DSRIP Performing Provider System. New York’s DSRIP program is an experiment. The hypothesis is that we can reduce unnecessary spending on acute care if we focus instead on the health of our population. Healthy people don’t need to go to the hospital. I would argue that this needn’t be just a hypothesis, as the data is clear:? we can. The harder question is whether we will. I’m reminded (again) of the old joke that my dad (the psychiatrist) used to tell:? “how many psychiatrists does it take to change a light-bulb Only one, but it needs to want to change.

The gap between what we humans can do (what we are capable of) and what we do (what we choose to do) is wide. We can exercise more, but we do not. We can stop eating trans-fats or foods with nitrosamines (both of which are well established to enhance the likelihood of disease) but we do not. People addicted to chemicals (nicotine, opioids, alcohol) can stop, but they do not always do so. Why don’t humans do what is objectively better for us We seem to have a reason to preserve the status quo. Why Why do we reflexively resist the people (or ideas) that ask if there’s a better way?

“People change in many different ways and for a multitude of reasons. The psychology of change is a broad and fascinating subject in its own right. In one sense, in fact, psychology is the science of change.” ? – William Miller & Stephen Rollnick in Motivational Interviewing Preparing People to Change Addictive Behavior.

So if innovation is about change, we need to understand the barriers to change. Only when change is embraced will the benefits of innovation be perceived to outweigh the risks. Now let’s get back to DSRIP and innovation.

Last week, we announced our second innovation award program. Last year, we awarded over $5.5 million to members of our community.

The purpose of the program this year is to nurture a culture of innovation in our region, with an emphasis on disruptive innovation.

Why are we focused on disruptive innovations Take a look at the classic graphic that Clayton Christensen often uses to explain the theory. Sustaining innovations improve existing products and processes, and improve the performance of existing markets. Disruptive innovations create new markets. They meet the needs of those who are not well served by the existing infrastructure, often because providing services to these folks is perceived by incumbents as low-margin and therefore not profitable.

Before you continue, please read this. It’s important, and, yes, if you are applying for one of our innovation awards, there will be a test (your application) at the end of this. As Christensen and team express, Disruptive Innovation is often invoked, but not always understood:

In our experience, too many people who speak of ?disruption? have not read a serious book or article on the subject. Too frequently, they use the term loosely to invoke the concept of innovation in support of whatever it is they wish to do. Many researchers, writers, and consultants use ?disruptive innovation? to describe?any?situation in which an industry is shaken up and previously successful incumbents stumble. But that?s much too broad a usage.

The difference between sustaining innovation and disruptive innovation may seem arbitrary for us and our innovation award program, but I would argue that it is not. The funding for this program is a small portion of the > $30 million that we are distributing the the community to help care delivery organizations migrate away from fee-for-service business models. Most of this money is supporting improvements to current processes, workflow, and technology. These are therefore, by definition, sustaining innovations.

The $4 million is therefore set aside to explicitly support activities at the low end of the health / health care market. For example, social determinants of health are often addressed by community-based organizations. Literacy, health literacy, housing, transportation, violence prevention and behavioral health are all matters that have enormous impact on the health of a community and the primary care and acute care services that are used. But these issues are low-margin (or have no near-term revenue model at all) and are therefore ignored for the most part by care delivery organizations (the incumbents).

Our goal is to provoke investment of time, strategic thinking, human resource allocation, and (most important) interest in meeting the needs of this “low end of the market.” This is disruptive innovation.

UPDATE: ?Here are the public records for the case. ?More details there about the original complaint. ?Excerpt:

@eClinicalWorks to pay $155M fine: https://t.co/RngioK62SX

But what’s it mean?

Certification

The purpose of any certification program is to create a method for the purchasers of a product to have confidence that the product safely and reliably does what it is supposed to do. ?One example from USDA:

In this case, the government moved to protect the public because a subset of meat packers was putting profit above public health. ?After The Jungle was published. public outcry caused the government to step in and regulate the industry. ?Regulation is not, therefore, a four letter word. ?It’s there to protect us from evildoers.

Before Health IT Certification

You may not remember this, but I do. ?Before there was certification, Health IT development companies (some people call them “vendors”) created software and sold the software with claims of improved provider productivity, improved public health, and (yup) improved billing (among other impressive?capabilities). Sometimes these claims were completely valid. ?Sometimes they were not. ?In the case where the developers’ functional claims were not quite valid, buyers had little recourse. ?One might say “well, the markets will take care of that. ?Bad actors will lose sales.” ?But that’s not the case here for several reasons:

1. The buyer may not be the one using the software. ?A hospital buys software for clinicians. ?Clinicians complain to hospital. ?Hospital may or may not be a strong advocate with developer.
2. It’s very hard to migrate from one system to another. ?EHR purchase / deployment / optimization is a multi-year initiative. ?If you bought a lemon, you may try to make lemonade as the though of migrating to something else will give you R11.0.
3. Shame. ?You don’t want your patients / competitors / peers to know that your EHR doesn’t work as expected. ?You made a mistake. ?Human nature is to hide our mistakes rather than treasure them as educational opportunities.

After Health IT Certification

The program isn’t perfect. ?I was on the developer side of this work from ~2006 – 2010 during the when CCHIT was the only certification path, and then for ONC’s first iteration of certification (2010 – 2011). ?Indeed, the imperfection of the program was a motivating factor for me to join the government in 2011. ?I wanted to help evolve the program toward perfection. ?Certification criteria needed to be less prescriptive (more flexible) but still provide sufficient guidance/ structure so that they could be reliably tested and replicated. ?This balance is hard to get right. ?Sometimes we got it wrong. ?Some have appropriately argued that there remains quite a bit of “check the box” busywork wherein health IT developers need to spend time building and configuring their software just to have it certified. ?”Trust us and don’t make us do this busywork” was the persistent message from the developer community. ?Recently, there have been renewed calls for scaling back the certification program and its many criteria, citing the maturation of the EHR incentive programs (meaningful use) and the fact that some of the certification criteria define capabilities that are not invoked by the incentive programs. ?The argument is that ONC has no place creating certification criteria for capabilities that aren’t part of “meaningful use.” ? I disagree. ?The ECW case is a great example of why I disagree.

About the eClinicalWorks settlement

What happened) You’ve read the press release from the Department of Justice by now. ?Excerpts (my emphasis added):

In its complaint-in-intervention, the government contends that ECW falsely obtained that certification for its EHR software when it concealed from its certifying entity that its software did not comply with the requirements for certification. For example, in order to pass certification testing without meeting the certification criteria for standardized drug codes, the company modified its software by ?hardcoding? only the drug codes required for testing. In other words, rather than programming the capability to retrieve any drug code from a complete database, ECW simply typed the 16 codes necessary for certification testing directly into its software. ECW?s software also did not accurately record user actions in an audit log, and in certain situations did not reliably record diagnostic imaging orders or perform drug interaction checks. In addition, ECW?s software failed to satisfy data portability requirements intended to permit healthcare providers to transfer patient data from ECW?s software to the software of other vendors. As a result of these and other deficiencies in its software, ECW caused the submission of false claims for federal incentive payments based on the use of ECW?s software.

As part of the settlement, ECW entered into a Corporate Integrity Agreement (CIA) with the HHS Office of Inspector General (HHS-OIG) covering the company?s EHR software. This innovative 5-year CIA requires, among other things, that ECW retain an Independent Software Quality Oversight Organization to assess ECW?s software quality control systems and provide written semi-annual reports to OIG and ECW documenting its reviews and recommendations. ECW must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks. The CIA also requires ECW to allow customers to obtain updated versions of their software free of charge and to give customers the option to have ECW transfer their data to another EHR software provider without penalties or service charges. ECW must also retain an Independent Review Organization to review ECW?s arrangements with health care providers to ensure compliance with the Anti-Kickback Statute.

Summary:

1. ECW faked their certification testing. ?The examples above are just examples. ?There are other instances wherein ECW faked the testing and convinced the testing body that the software could do something that it could not do.
2. Since the software was not certified, any physician or hospital who received incentive money and attested to the use of certified software was in fact fraudulently attesting to the meaningful use of certified software.
3. The Corporate Integrity Agreement (CIA) commits ECW to:
   1. Oversight from an independent third party
   2. Notify customers of any safety risks (there are many)
   3. Provide software updates for free
   4. Support migration to other EHRs for free

So what?

Reminder: ?The purpose of any certification program is to create a method for the purchasers of a product to confirm that the product safely and reliably does what it is supposed to do.

• ECW is a big company, with ample resources. ?Their software is used by tens of thousands of clinicians every day. ?The lives of their patients (many of whom are Medicaid beneficiaries – as many federally qualified health centers use ECW) depend on the safety and reliability of this software.
• ECW’s software doesn’t do what they claim. ?Now that the government has investigated, and is holding them accountable, the message is clear: ?the public’s interest is being protected.
• ECW is not the only organization that cheated on certification. ?They may have been the biggest, boldest violator, but they were not the only one. ?Others have already started internal reviews of their own performance, and those who have not yet done so are very likely to do so tomorrow. ?This case is a wake-up call for the CEOs of all EHR development organizations to dig deep, and have honest direct conversations with the small teams that prepared the software for certification testing, and performed certification testing with the test labs. ?My advice to these CEOs: ?look these teams?in the eye and ask “is the software that was tested exactly the same as the software that is available to all of our customers?” ?In many cases, the answer is no. ?As Farzad tweeted today, a very common case is in the domain of interoperability: ?can the system exchange data as it was certified to do) All too often, the answer, when we speak with the EHR developers, is “yes, if you pay us $$$ to enable that capability for you.”

Today’s announcement is the culmination of several years of work – all focused on protecting the public and holding a company accountable. ? As I’ve asserted both privately and publicly, the regulatory infrastructure of EHR certification is important because sometimes there will be bad actors. ?While the “good actors” may be inconvenienced and annoyed by processes that seem unnecessary, for such important elements of our nation’s health infrastructure, we can’t have government abdicate this responsibility. ?With or without the incentives programs, or MIPS, or 21st Century Cures, there is a set of capabilities that these systems need to have, and for which they must be certified. ?The breadth of this set of requirements, and the depth of certification testing for any criterion are the needles that must be threaded. ?I’m confident that Don Rucker and the team at ONC can navigate the balance well.