Western Thoracic Surgical Association 2013 presidential address: Winning the HITECH challenge
2013; Elsevier BV; Volume: 146; Issue: 5 Linguagem: Inglês
10.1016/j.jtcvs.2013.07.035
ISSN1097-685X
Autores Tópico(s)Advances in Oncology and Radiotherapy
ResumoIt is heartwarming for me to be presented to you by Tom Burdon, a distinguished colleague and sincere friend. A “thank you” to Bobby, our immediate past president for his leading our strategic planning. I want to thank you all for joining us as we celebrate a wonderful tradition: the address of a new president. Your presence honors the Western Thoracic Surgical Association (WTSA), which members affectionately refer to as the Western. WTSA is an association that has been strengthened throughout its history by upholding the highest values of science, integrity, collegiality, and openness to people from around the world. By being here today, you are stating your desire for us to continue embodying everything that is good and principled about self-learning. I humbly recognize that I am just the guardian of something much larger than myself and much larger than all of us. I am the temporary guardian of an organization that means so much to so many, and, in that capacity, I sincerely thank you all for being here. I want to offer a special greeting to those families present, which are among WTSA’s friends—you are the great force who lives out our dreams. I am deeply grateful for the company of our many distinguished colleagues from all over the world. We need you here, of course, to make the day seem properly serious. It is good to confirm that the presidents of the WTSA do look presidential in their roles as I am trying in mine. I must express how honored I am to have been so chosen: As a simple, community cardiothoracic surgeon. Fifteen years ago, I became a member, and like most initiates, I knew surprising little about the “Western” culture. I distinctly recall wearing a suit and tie at my first scientific session, and I believe I have not sported another at our annual meeting until today. You might wonder why I dressed the way I did: As a new member attending his first ever Western meeting, I erroneously assumed STS (Society of Thoracic Surgeons) etiquette! Let me again welcome our 19 new members of 2013 and invite them to participate in the discussions throughout our stay in Coeur D’Alene. A presidential address is a privilege accorded to few, and the only occasion at which the choice of the topic is entirely up to the speaker and the content is not reviewed by a program committee. Perhaps the only restriction advised is that one would direct the discourse toward something the speaker knows about firsthand. As I researched suitable topics, I learned that history has been done well at previous meetings, also biography, surgical education, and health care reform. I concluded that it would be best to address you on a subject of urgency and one that I have spent the past few years struggling with—relevant learning in the era of big data. We live in evolving times, particularly as related to our chosen profession of thoracic surgery. Despite the remarkable clinical advances that have occurred during the past century, monumental changes are upon us; I find it hard to believe the heart and lung machine is 60 years young this year. A recent, rapid convergence of ideas in digital medicine has the potential to provide a better health delivery system for our nation. The uniqueness of the surgeon will be invaluable during this evolution. Surgeons think and work differently; we are not interchangeable with internists, physician assistants, nurse practitioners, or hospital administrators, even though we are all essential members of the 21st century surgical team. Back in 1999, remaining in a full-time academic environment posed unique challenges: Medical schools lacked funds, and dedicated research time was disappearing rapidly. I was lucky to be offered the opportunity to completely internalize the Hawaii Kaiser Permanente Thoracic Surgery Program. Back in those days, our corporate preferred Web browser was Netscape, and the company E-mail system did not accept attachments, so I kept my college E-mail address that I still use today. In fact, a young “JChen12” (2012) at MIT recently sent me a message, hoping to figure out who has the “JChen@alum.mit.edu” address. E-mail afforded me the ability to continue collaborations across the Pacific Ocean without the delay of “Par Avion.” I believe everyone in this room today has a thoughtfully chosen E-mail address, but the increase in Internet traffic has made communication more difficult. Ten years ago, I looked forward to checking E-mail; today, it has become a daily deleting and reporting spam expedition. Since I was born in Taiwan, let me start with a couple of Chinese characters. It is traditional to read right to left. 險危—Danger 會機—Possibilities or opportunity The other thing the Chinese do is read from top down. 危機—Critical turning point or crisis To this day, I am convinced this is why I have shuffled English grammar. In Proust and the Squid, Maryanne Wolf theorizes the act of reading Chinese characters has shaped the Chinese reading brain, and that a person who learns to read in Chinese uses a particular set of neuronal connections that differ from the pathways used in reading based on the alphabetic principle.1Wolf M. The birth of an alphabet and Socrates’ protest.in: Proust and the Squid: The Story and Science of the Reading Brain. Harper Collins, New York2007: 60-78Google Scholar When written in Chinese, the word “crisis” is composed of 2 characters: One represents danger and the other represents opportunity. This play on words probably gained momentum when John F. Kennedy delivered a 1959 speech in Indianapolis. The usage has since been adopted by business consultants and has attracted attention in universities and the popular press. I truly believe US health care is the best in the world, but our spending has been increasing faster than the incomes of most developed countries, which raises questions about how we will pay for our future health care needs. Our health care system is at a critical turning point, and we are in need of an innovative fix. At the 2012 Clinical Congress of the American College of Surgeons, much discussion focused on the continual increase in US health care expenditures and implementation of the “Patient Protection and Affordable Care Act,” commonly abbreviated as the “ACA for Affordable Care Act.” Recent data from the Organization for Economic Co-operation and Development (OECD) reveal the United States has the highest growth per capita health care spending of the 15 countries that rank in the top three fifths of national income. The Organization for Economic Co-operation and Development is an international organization that collects and analyses data based on various social and economic indicators. We would agree that if the United States in this graph were a stock in the Standard and Poor’s 500, we would all invest in this company first thing tomorrow morning; however, this is our rising health care expenditure for the past 4 decades and unsustainable. How many of you have received E-mails to click for repeal of the “sick” Medicare Sustainable Growth Rate (SGR)? How many of us have actually done so or taken an interest in the details? Less than one fourth of STS members who receive action alerts click through to send messages to their members of Congress about any aspect of health reform legislation. We need to click to better health care. Every year since 1997, the Center for Medicare Services has sent a report to the Medicare Payment Advisory Commission, which advises US Congress on the previous year's total health care expenditures. The report includes a conversion factor that changes the payments for physician services over the next year to match a target annual SGR formula. If the expenditures for the previous year exceeded the target expenditures, the conversion factor will decrease the payments for the next year. On March 1 of each year, the physician fee schedule is updated accordingly. The implementation of the fee schedule to meet the target SGR can be adjusted by Congress, which has been done regularly in the recent past. A last minute adjustment can be characterized as paying the minimum on our credit card bills and allowing the principle to accrue and compound interest debt. How many of us would choose to do this with our credit cards indefinitely? Physician groups such as the American College of Surgeons and STS have been lobbying to Congress for SGR reform and need our help. We must first take interest, if we are to take action. At this year’s STS meeting in Los Angeles, Dr John Mayer suggested that we support specialty-specific SGR. One of the highlighted SGR flaws is the concept of collective accountability; all providers face the same fee changes, regardless of their spending. A study in the New England Journal of Medicine last year estimated excess SGR target spending by selected specialties.2Alhassani A. Chandra A. Chernew M.E. The sources of the SGR “hole.”.N Engl J Med. 2012; 366: 289-291Crossref PubMed Scopus (39) Google Scholar Cardiothoracic surgery is one of the highest valued specialties in the SGR formula. The STS political action committee has proposed the following principles for specialty-specific reform of the SGR formula:1.The physician payment system should ensure that individual medical specialties can control the growth rate of their services and payments by identifying the most effective and appropriate treatment for the patient.2.Specialties should not be penalized if their quality and value improvement activities result in lower Medicare expenditures, otherwise known as the gainsharing initiative.3.The STS National Database should be used in sharing outcomes data to allow physicians to change their practice patterns to achieve better results, more efficient delivery, and increased patient value. Government legislators act only in times of crisis, as reflected by Congress’ approach to save ourselves after going over the fiscal cliff this past New Year’s Day. We need to take action with the SGR and support regional health care reform events when the opportunities arise. When you volunteer to help with reform, it does not matter how fast you go, so long as you do not stop. Government service can be risky to the reputations of those who volunteer, but knowing that you can go back to surgery is empowering. Physicians early or late in their careers often have supportive health systems to return to. Young surgeons can return to junior faculty positions or practices and resume the climb up the career ladder to which they aspire. Their service will be seen as an extension of professional development. More senior surgeons will often have acquired standing in their community that provides them considerable professional security. There will be emerging opportunities and dangers to physician practices and health care delivery for all Americans. This will be due in large part to the continued enactment of the Affordable Care Act (ACA) and a projected physician shortage. This, I believe, is an example of a reverse innovation. Very simply, a reverse innovation is any innovation likely to be adopted first outside the United States. It is so-called because historically nearly all innovations have been adopted first in rich countries. It has been argued that reverse innovation will become more and more common, and that it presents a formidable organizational challenge for incumbents in the developed world. Reverse innovation is not synonymous with disruptive innovation. A disruptive innovation has a particular dynamic that endangers the incumbents. Typically, a new product has 2 primary dimensions of merit (eg, A and B). “A” could be quality and “B” could be service. Mainstream customers are mostly interested in quality, but a minority of customers will value service more than quality. The disruptive innovation, at launch, will be weak on quality but overdeliver on service. As such, it attracts only the minority. Because mainstream customers do not want it, incumbents tend to ignore the new entrant and the new technology. However, over time, the technology improves and the innovation becomes better and better at quality. Eventually, it meets the needs of mainstream customers on dimension quality, and, because they also place at least some worth on service, they choose the new product. The incumbent is suddenly disrupted; they have ignored the new technology all along. A good example of this is the Apple iOS operating system’s lower spam index compared with Microsoft Windows. When quality improves for a lower price, economists term this increased value in mathematical terms:Value=Quality/Price One of the unarguable goals of the ACA is to add value to our health care system. Whether a product innovation is disruptive or reverse, or both, it is difficult for an organization to execute a change in established practices. For reverse innovations, companies must overcome resistance to shifting control away from the headquarters and status quo. For disruptive innovations, companies must overcome the initial resistance to prioritizing an investment that does not interest mainstream customers. Also, if they do invest, they must overcome the fear that the new product might cannibalize the existing business. However, despite these difficulties associated with change, the vast majority would agree that the US health care system is not sustainable and that we are in need of an innovative fix. Disruption has been the new mantra of our lives this decade. To get at the root of disruption, I would like to discuss Disrupting Class, by Clayton Christensen, for a few minutes.3Christensen C.M. Horn M.B. Johnson C.W. Disruptively deploying computers.in: Disrupting Class: How Disruptive Innovation Will Change the Way the World Learns. McGraw Hill, New York2011: 96-104Google Scholar Although this is a book about the modern challenges of residential higher education, I believe the concepts are central to our experiences with the ACA. Historically, there has been a similarly inelastic economic demand for both higher education and health care. In the section of the book titled “How to implement computer based learning: Lessons from Rachmaninoff,” Christensen asks us to imagine what would be if RCA Victor, the early pioneer of the recording industry, had marketed its products to be played after intermission of a live symphony concert to allow the performers to go home early. The theater audience would have been delighted with the sound quality of the Victrola phonograph but would have been deeply disappointed when the Rachmaninoff recording was pitted head-on against the live musicians. Fortunately for the recording industry, RCA Victor sold its phonographs to people who could not go to Carnegie Hall. Today, nearly everyone hears most of their music through recordings as opposed to in person. Quite simply, disruptive innovations can be summarized as those new technologies that cater to a social class that believe any innovation is more than they have; in contrast, a sustaining innovation targets those that always want more than they have. In Disrupting Class, Christensen also related disruptive innovation to the modern day and inferred that the World Wide Web has allowed us to customize how we learn. He has urged us to seize the opportunity to reap the benefits of such innovation; whether we learn best through linguistic, math (logical), spatial, bodily (kinesthetic), musical, naturalistic, or interpersonal methods, the Internet has provided us a portal to these resources at all times. He hypothesized that when an educational approach is aligned with one’s intellectual aptitudes, understanding can come with greater enthusiasm and more easily. The ACA will urge us rapidly to enroll 20 million “disruptive” Americans with income gaps into our health care system through the establishment of health insurance exchanges. These will increase the need for a new infrastructure of doctors and exacerbate an ongoing physician shortage. This shortage of doctors is also driven by the rapid expansion of Americans older than 65 and a 13-year freeze of Medicare support for graduate medical education. Together, these factors are expected to produce a projected decrease of some 91,000 physicians compared with our current workforce by 2020. Data have shown a 7% decrease will occur during the next 10 years in many surgical subspecialties, including thoracic surgery, urology, and rural general surgery. The ongoing physician shortage has been exacerbated because initiatives to improve both quality and cost of health care through novel care models and implementation of electronic medical records (EMRs) have caused dismay among our senior colleagues. The “Health Information Technology for Economic and Clinical Health” (HITECH) Act portion of the ACA is currently being enacted. Among the many goals, this ACA bill targets increased use of health information technology by requiring the government to take a leadership role in developing standards that allow for the nationwide use of EMR to improve quality and coordination of care. The bill stipulates an investment of $20 billion in electronic infrastructure and Medicare and Medicaid incentives to encourage doctors and hospitals to digitally exchange patients’ medical records. The fundamental question is: what universal mechanisms can be developed to influence current physician practice to add value and achieve the goals of better care and better community health? As a result of this legislation, the Congressional Budget Office has estimated that 90% of doctors and 70% of hospitals will be using comprehensive EMRs within the next decade. A recent survey from the Centers for Disease Control showed physician adoption of EMRs was ahead of projections. The HITECH Act legislation provides immediate funding for computer training, dissemination of best practices, telemedicine, and clinical education to promote health information technology. In addition, the legislation has provided significant financial incentives through programs to encourage doctors and hospitals to adopt and use certified EMRs. Physicians are eligible for up to $65,000 in reimbursements for showing that they are meaningfully using health information technology through the reporting of defined quality measures. I respectfully submit that we must take action in leading the definition of meaningful quality measures in thoracic surgery. If we do not determine our future, someone else will. In 2005, the possibilities were great, and our medical group began creating the virtual fourth space; we went all in with the HITECH Act in 2009. The risk we took with populating the digital fourth space was screen monitor fatigue and what we later estimated to be 10% of our senior medical staff’s elected retirement as soon as they were eligible for their benefits. Ultimately, the changes on us could require many surgeons to align with health systems to achieve national quality initiatives and secure cost reductions and economic stability. I must admit that at times it really seems we have lots of information technology but no relevant information. The implementation of computerized medical records has been a 40-year story for our health plan. It was a vision of Dr Sidney Garfield, the physician responsible for creating the Kaiser Permanente medical care delivery system. Since inception, Dr Garfield fought for the fundamental principle that physicians must be involved and responsible for administrative decisions that affect the quality of the care they provide. He published this concept and that of a computer center in the April 1970 issue of Scientific American.4Garfield S.R. The delivery of medical care.Sci Am. 1970; 222: 15-23Crossref PubMed Scopus (97) Google Scholar EMRs later gained widespread public attention some 30 years later when President George W. Bush in his State of the Union speech called for digitizing the national health records. There is much organizational memory surrounding the adoption of the Kaiser Permanente computer center. I actually believe the “computer center” is a misnomer: according to the Merriam-Webster Dictionary, to “compute” is to determine by mathematical means or calculate. When is the last time you used your computer to compute? I believe Dr Garfield’s vision was a knowledge management center. Hawaii Kaiser Permanente was the ideal test site for EMRs because of our patient population and medical group size. Our first experience with EMRs was with an IBM product in 1999 that did not perform as anticipated. Using HITECH to foster efficient health care delivery is an important component of the ACA, but where are the savings? A study in JAMA 2012 assessed the association between online access and the use of clinical services. Several previous studies have suggested that online access could replace a patient’s need for face-to-face health care services.5Palen T.E. Ross C. Powers J.D. Xu S. Association of online patient access to clinicians and medical records with use of clinical services.JAMA. 2012; 308: 2012-2019Crossref PubMed Scopus (133) Google Scholar Patients with online access and E-mail communication demonstrated an unexpected increase in the use of in-person and telephone clinical services. In the year following activation, represented by the “zero” line, members with such access had increased rates of office visitations, telephone encounters, and acute cares services compared with a matched cohort of members without online access. These findings were consistent in both younger and older individuals and for those without chronic health conditions. The Institute of Medicine recently asserted, “Clinicians increasingly are barraged with a vast volume of evidence of uncertain value.” The availability of a large amount of information in integrated electronic databases can provide a quantitative basis for evaluating treatment outcomes, but it is up to us to synthesize it. By combining patient data in shared registries, we can correlate demographic variables with operative results and long-term survival. We recently queried the Epic Kaiser Healthconnect EMRs, administrative databases, and the Social Security Death Index to assess the 10-year patient survival after more than 3000 mitral valve operations among 4 cardiac surgical centers in California and Hawaii and encountered a few surprising findings. Our publication this spring showed that, despite increasing recent implants of tissue valves, we found better 10-year Cox regression-adjusted survival after mitral valve replacement with a mechanical prosthesis in patients both younger and older than 65 years of age, leading us to the hypothesis that 75 might be the new 65 (available at: http://www.thepermanentejournal.org/files/Spring2013/MitralValve.pdf). I chose this example to demonstrate an important mathematical concept: The distinction between correlation and causation. Understanding the difference is perhaps best described in The House Advantage, by Jeffrey Ma6Ma J. Think like a scientist.in: The House Advantage: Playing the Odds to Win Big in Business. Palgrave Macmillan, New York2010: 56-61Google Scholar (some of you might recognize his name from the movie Twenty-One). During the information revolution, 2 “camps” have emerged—the “computer people” and the “scientists.” The computer people tend to focus on data mining and patterns that can be correlated. The scientists believe in the causal power of fundamental testing. The problem with large data sets is that they can be quickly analyzed in a variety of ways through today’s computing software and patterns can quickly emerge, but these patterns can be misinterpreted as stemming from a fundamental cause rather than from random chance. Computer people do not necessarily concern themselves with whether the relationship they discover is truly causal. Let me provide an example: Hypertension and cardiovascular disease is causal, but it is also correlated, because people with hypertension have a higher incidence of cardiovascular disease. Many hypertensive patients eat “pommes frites”; thus, hypertension and eating French fries are often seen together and therefore are correlated. However, eating “pommes frites” does not necessarily cause hypertension or vice versa. There are many computer people today, but we surgeons are, first, scientists by training. We must take interest in the scientific validity of the computer people and seize every opportunity to challenge their interpretation of our practices. Care of the surgical patient is an amalgamation of cognitive thinking, technical ability, and clinical judgment. Years of training are required to achieve the synergy of skills necessary to earn the trust of the patient in need of operative care. Traditionally, the patient–surgeon interaction has been managed as a private bond based on trust and mutual respect. As the American health care system has evolved, however, numerous extrinsic factors have radically changed this relationship. Expanding administrative “clicking” has robbed clinical time from health care providers and patients alike. Increasing productivity demands by a financially challenged health care delivery system has turned the surgeon–patient interaction into a time-limited check list encounter that plants the seeds of stress and mistrust on both sides. More than 13,000 health and medical apps are available for mobile devices. Information was power before the advent of the smartphone, but trust and judgment will be the currency of the digital era. As you can see, the risks are great. But I promised you that I will focus on the opportunities—and I believe the opportunities are even greater than the risks. The pressures of cost and the potential of the HITECH Act are presenting all of us in medicine with a historic possibility: The possibility to better serve society by reinventing what we do and how we do it. It is an opportunity we must capitalize on. Let me be clear: Of course, we need to help contain costs and continue to seek greater efficiency. Of course, we need to continue to provide excellent surgical care. However, history has assigned us an even bigger challenge—a challenge that requires a solution of great commitment and scale. How do we put all of this together; how do we synthesize the vast amounts of information coming at us? Let me suggest that we must first remember what it is that we do. Googled facts, deception, and fantasy throw speed bumps at the surgeries we are asked to do. Uncertainty is the enemy of confidence, and, without confidence, we cannot perform thoracic surgery. Danger is at every turn in the operating theater. More important than ever, we must take time to explain what is relevant and important. One problem created by the information tsunami, especially for analysts, is that too much information is available. An informal social contract that exists among many virtual communities is that people act as software agents for one another. The agreement requires virtual citizens to keep an eye out for one another’s interests, whom they never plan to meet, while they explore new sectors of information. The bureaucracy of the big data environment will challenge our surgical culture of face-to-face interactions. Operating in a corporate environment is not in most medical school curricula, but winning in competition and liking challenge are at the cores of our specialty. Working in a large corporation has been well described by former CEO of General Electric, Jack Walsh, in his book titled Winning—a must read if you are contemplating long-term contracted employment. I would not do Mr Walsh justice by speaking about his chapter on Winning during a crisis in this address, but will refer you to the YouTube link (http://www.youtube.com/watch?v=PxU6Z0BgyWM). “That which does not kill us makes us stronger” is a quotation by the German philosopher Friedrich Nietzsche (and not a song by Kelly Clarkson, even though she owns the Grammy Pop Album of this year). Nietzsche also professed that our way of thinking changes through way we live and through the tools we use. Adapting to the HITECH Act did something funny to my brain—it made it more “Internet-smart.” Functional magnetic resonance imaging studies by Small and colleague7Small G.W. Moody T.D. Siddarth P. Bookheimer S.Y. Your brain on Google: patterns of cerebral activation during internet searching.Am J Geriatr Psychiatry. 2009; 17: 116-126Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar titled “Your brain on Google” compared the “Internet-savvy” and “Internet-naïve” brain. There are 2 different schools of thought on their findings. One is that when you first embark on an Internet search, you require greater activity and more judgment, and that one would expect higher levels of activity, as if you were learning a new task. What their results showed is that while Googling for the best restaurants, savvy people actively engage decision-making areas on functional magnetic resonance imaging but Internet-naïve people can be overwhelmed by the situation and just read it as they would a book—they are not trying to integrate all the available information. The other interpretation is that Internet-naïve people just have a different pattern of wiring in their brains from those who are Internet-savvy—that is, people who prefer using the Internet and enjoy that mode of reading are wired differently from the Internet-naïve people. We could not distinguish that in their study. I believe adapting to the HITECH Act might have transformed my brain from simply reading information to synthesizing what is relevant online and that the HITECH Act will entice you to learn by empirically searching for the right buttons while you are checking on your patients at 4 am. One thing is clear, the Internet-savvy brain during a Web search uses energy and mental fortitude. A real need exists to carefully manage yourse
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