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E-Health Networks The New Shape of Public Health

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Presentation on theme: "E-Health Networks The New Shape of Public Health"— Presentation transcript:

1 E-Health Networks The New Shape of Public Health
NGA State Alliance for e-Health 2nd Annual State Learning Forum Stephen Goldsmith Daniel Paul Professor of Government Director, Innovations in American Government Program Harvard University John F. Kennedy School of Government Developed in conjunction with Deloitte Center of Health Solutions and Deloitte Research

2 Traditional Bureaucracy Is Inadequate
Agency 1 Division Unit Agency 2 Agency 3 Department Bureau Citizen In the interest of both the left and the right to maintain the illusion that this, the traditional way, we think of government still represents how government gets its work done today. It allows the left to maintain the illusion that every time a government uses a contractor to do a service that that is somehow something very radical and different and the right to blame the failings of government on inane bureaucrats. But this view has become obsolete.

3 The New Shape of Government
NGOs State Government Health Provider Local Government CCID Organization International NGOs Hospitals While government agencies, bureaus, divisions, units and offices haven’t gone away, when it comes to delivering services to citizens, they are becoming less important than the web of multi-organizational, multi-governmental and multi-sectoral relationships that now constitute modern government. The public sector is becoming more of a broker of activities and services rather than a direct service provider. It resembles less the organizational chart of old and more like a computer network. The role of public managers, in turn, is transformed from supervising vast divisions of public employees to arranging and managing networks. Federal Agency

4 Models of Government High Low Low High Public-Private Partnerships
Networked government Level of public/private collaboration Outsourcing alone cannot cure the problems of hierarchal government. When a stove-piped government bureaucracy contracts a service to a private company, citizens still receive the service through a narrow, isolated silo, and dealing with four contractors, for example, isn’t much of an improvement over interacting with four government agencies. Joined up not reflect reality of private-sector delivery Hierarchical government Joined up government Low Low Network mgt. Capabilities High

5 Information dissemination DEGREE OF GOVERNMENT INVOLVEMENT
Types of Networks Supply chain Civic switchboard Information dissemination Intergovernmental Ad hoc More DEGREE OF GOVERNMENT INVOLVEMENT Less Service contract Channel partnership

6 Networked Organization Models that HIT Can Learn From
Hurricane Katrina Response SARS Establish that they required public-private partnerships Anthrax Crisis Response

7 Governing by Network has Many Advantages…
Improved Speed and flexibility Specialization Networked government benefits Flexibility. Networks tend to be more flexible and nimble than hierarchies. A neighborhood center, for example, can more easily direct a struggling young mother into a personalized mix of shelter, counseling, or training facilities through a public/private network than through direct government service delivery because it can leverage the skills of a range of providers. Innovation. Networks typically provide more innovative solutions to problems than traditional, rule-bound governments. Within months of securing contracts to administer welfare and employment programs in six Wisconsin counties, the Forward Service Corporation, a regional nonprofit agency, obtained additional housing, transportation, and education grants from federal and private sources, enabling the organization to provide a far greater array of client services than had previously been provided by the counties. Specialization. Network approaches allow a government to concentrate on its core mission by leveraging the expertise of “best of breed” providers. Many school districts, for example, partner with private sector organizations, which apply their specialized technology and management skills to deliver everything from remedial education to school management services. Speed. The decentralized, fluid form of a network and the autonomy of each member allows for decision making at the local level. This, along with the ability to rapidly access information at critical times, improves the speed and efficiency of decision making. Increased reach Innovation

8 What a Health Network Might Look Like

9 State HIE Network Model
Now there is billions of dollars that enables state information exchanges, puts the state in the LEAD ROLE AS SOMEONE WHO BRINGS TOGETHER REGIONAL EXCHANGES AND PROVIDES FUNDAMENTAL SERVICES TO BRING PEOPLE TOGETHER Connecting on technology level, level of getting various proxies, various groups (pay as provider, citizen) == different groups comes together and the govt brings together all these groups State benefits by all things coming together – much better quality of care, healthier citizens (under served and under insured) – this reduces the burden of Medicaid which is biggest portion of budget; making for other citizens better access to care

10 Health Information Exchanges the health information network
The “big picture” of the health information network Federal NHIN National Health Information Network State HIE HI grant & Regional Center grant HIE grant – state gets it and then distributes funds The state builds upon existing networks Regional Center grant – support for the providers so that they can be part of the solution Both coming from ONC, total to 1.2 billion, grants publically announced RHIO RHIO Network Health Networks Network Health Networks

11 The Many Roles of Government
States Can Play Many Roles in an HIE Network Convener Educator Administrator Policy Maker Initiator/ Catalyst Operator Coordinator States must lead the change. …in collaboration with health consortiums, citizens, payers, providers, and others.

12 Issues and Delivery Networks Possible Organizations
Your Role Schools Role of the Private Sector Obesity Mental Health Local Non Profits National Foundations State Health Policy and Finance Information Sharing and Incentives Managing the Network Sector partners, travelers, the private sector, and the other government agencies all respond to regulation, but there are many other “soft” ways of achieving the mission. Relation to Other Sectors Public Hospital and Community Health Child Welfare Infant Mortality Information Sharing Needs = Sector 1 = Sector 2 12

13 Key Principles to Create Networked Model
Define of Public Value Carefully Better Health, Not Better Transactions Design Network Correctly—Understand All Assets Quality Decision Making Congruence of Goals Build Skills and Capacity Network Leadership

14 1. New Role for Government: Focus on Public Value
Before: DC General Hospital After: DC Health Care Networks, From One to Many Instead, by explicitly focusing on maximizing public value, the range of potential solutions typically widens to include the private and nonprofit sectors as well as other levels of government. Instead of seeing their jobs mostly as managing public employees, public executives will view their role as resolving how to add maximum public value by deploying and orchestrating a network of assets. WDC story. Instead of asking, “How can we fix the hospital?” Tony Williams asked a more fundamental question: “Is it my job to run a public hospital or to provide the maximum public health for the indigent?”

15 Public Value Definition
The point of all activity is for each party to create value Government role: to transform existing social conditions in collectively desired directions Demonstrations of value creation lie in evidence showing changes in conditions Problem: Not everyone sees value in the same way

16 Different Ideas of Value
Satisfy patient demands Produce Better Health Reduce Costs Make a Profit Meet Social Needs Achieve a Just Society

17 Four Programmatic Areas Behind The Curve to Reduce Cost and Improve Care
Consumerism Coordination of Care Comparative Effectiveness/Evidence-based Medicine Healthcare Information Technology

18 Examples of How Electronic Systems Drive Better Outcomes
Care Management Improve care while managing costs, maximizing the health care investment. Care management, disease management, and utilization review. Electronic Health Records/Health Information Exchange Improve quality of care and enhance service to individuals. Patient Data Hub, allowing for the integration of disparate healthcare data sources and follow-on analysis to produce actionable information at the point of care. Emergency Department Diversion Prevent overcrowding, promote wellness, and make better use of scarce resources. Proactive medical management. Through data analysis of historical medical claims, access analysis, and education techniques. Lower ED usage. Long-Term Care / Renal Care Audits Detect and correct errors and prevent future overpayments. Make better use of data to improve care to individuals. Nursing Home Diversion Manage ongoing healthcare costs and provide care where it’s needed.

19 Pennsylvania NEDSS system
2. Design Network: Map Parties, Understand Tools 2. Design Network: Map Parties, Understand Tools Pennsylvania NEDSS system The development of PA-NEDSS has allowed the Pennsylvania Department of Health to cut the reporting cycle patient cases from 3 weeks to fewer than 24 hours. PA NEDS Patient centric system that secures lab results from across the state and enables investigators in real time to go in and make decisions from these lab results it works, has been around for 5-7 years; connects state, CDCS, labs, partners, all across the state You can build upon this because it is a existing network, you can connect this to another network that also exists in another region of the state

20 PA-NEDSS – An HIE Making a Difference
Working Example : Extending Existing Public Health Systems to Serve as HIE channels; All Actors Work Toward Same Goal PA-NEDSS – An HIE Making a Difference Local & State Health Departments Patient Centric System Health Information Technology Physicians 700+ Privacy Centric & Secure Point of Care Data Entry Investigators HL7 based HIE EDR App Integrated Data Collection, Management, Analysis, Transmission, and Dissemination Epi-X Rapid reporting and discussion of health events, 24/7 access to key officials and expert assistance Linked Disease Reports More Complete Patient View Real-time Data Collection Master Patient Index Hospitals Patient Search & Match 400+ More Timely Intervention Health Alert Network DOH Central Office De-duplication OTHER EXAMPLE – VA Electronic Records: The core innovation for which the VHA has applied to the Innovations Program is VistA. In its current version, VistA enables clinicians to place clinical orders and find, organize and analyze rapidly a VA patient’s complete medical record, including medical imaging (x-ray, CT scans, MRIs,and video imaging), lab test results, allergies, prescribed medications, progress notes, consults and discharge summaries. VistA is innovative because it is national in scope and integrates clinical information across diverse health care settings: community health centers, hospitals, including intensive care units, long-term care institutions and some home care settings. Also, the whole record is longitudinal and therefore enables quick reviews of long patient histories while at the same time allowing for direct real-time data access and communication among all VHA providers across the entire system. Bio-terrorism Rapid Detection Rapid Response Enabler Laboratories CDC 170+ 20

21 Decide Who Should Do the Integrating
1 Subcontractor Government Contractor Subcontractor Subcontractor Contractor Contractor Government Subcontractor Subcontractor Contractor Subcontractor Subcontractor 2 Prime Contractor Subcontractor Government Prime Contractor One key element of a strong design is figuring out who should integrate the network. A strong integrator that can coordinate activities, handle problems, and ensure the provision of quality services is necc. Acts as the “hub” and often is the only entity with links to all the other network participants. Government officials have three choices: Government A prime contractor A third party In many respects, the public sector represents a logical choice as the integrator. Yet government also faces some real challenges in being its own integrator. It requires the government executive to think creatively across service lines and agencies, build an intergovernmental network, and find internal management talent that can creatively configure the best possible solution. Absent this, the government executive must recognize that the skill of an outside provider to properly integrate the parties may, in fact, be the most important asset to procure. GO THROUGH OTHERS Key thing is that this thought process needs to take place and be done carefully and systematically. 3 Third Party Private Provider Contractor Subcontractor Government Third Party

22 Do Don’t Use multiple levers to build and activate networks
Manage each network the same way Your Role Role of Other Government Agencies Role of the Private Sector Education and Rhetoric Money Managing the Network Information Sharing and Incentives Sector partners, travelers, the private sector, and the other government agencies all respond to regulation, but there are many other “soft” ways of achieving the mission. Relation to Other Sectors Regulations Capacity to Convene Sector Scale Information Sharing Needs = Sector 1 = Sector 2

23 3. Quality Decision Making: Numerous Challenges
Driving network governance vision down the organization Training and recruiting for the new skill sets (and cultural change) needed Treating partners as real partners Developing and enforcing shared outcome goals Horizontal management in a vertical government Government as 800 pound gorilla

24 4. Aligned Values and Incentives
4. Aligning Values and Incentives Congruence of Goals: Develop the Network Design 4. Aligned Values and Incentives Congruence of Goals: Develop the Network Design What Goal of network? How Levers used to initiate and sustain network? Type of network? Identify each parties goals Who Partners in the network? Who integrates network?

25 Share - Don’t offload risk
Guidelines for Sharing Risk Which network partners are best at managing which risks? Who is bringing the bulk of innovation to the table? How much control does the public sector have over the network and/or over the particular risk involved? Are the contract costs of the risk shifting worth it? Are the risks actually regulatory in nature? KS Example Nearly all financial and performance risk was initially transferred to the nonprofit providers through the use of a capitated managed care model which required them to deliver all required services, regardless of the costs. On paper, the risk transfer made eminent sense. The contractors could earn a slight profit if they were able to quickly get children in permanency positions; if they failed to do so, they could bear some financial losses. The idea was to align the economic incentives of the contractors with the program goals of the agency. In practice, the risk shifting didn’t work out nearly as well as hoped. Mental health costs for the children were dramatically higher than anyone anticipated. Two of the nonprofits that won initial multimillion contracts had an extraordinarily difficult time scaling their staff back when they lost the contracts when they were re-bid several years later. In the end, several nonprofits who were awarded contracts proved unable to bear the hefty financial risks imposed by the state and ended up declaring bankruptcy.

26 Assuring the Performance of Networked Arrangements
Which have Worked? Define Best Practices Public Health “Networks” Characteristics of “Networks” What Could Work Better? Future “Networks” How about formal agreements, aligned incentives, leadership (CEO level) support, etc.? Critical to determine “wants” and assure the network meets these. Successful networked arrangements; Healthy People 2010 Financial support to State & Local HDs Contracting agreements Extramural research Biosurveillance Not so successful arrangements; NEDSS Monitor Performance 26

27 A Life Cycle Approach to Performance
Set Goals/Align Values Structure Incentives/ Share Risk Achieving results from networks PREVENTATIVE: Particular to MEDICAID: CMS issued a letter at a 90/10 match to Medicaid agencies to implement health information exchanges Now it is upon the state to pull together as part of the HIE application, pull in Medicaid an tie them together and get them into the care coordination model (That is where you get the biggest bang for your buck) Manage Change Measure Network Performance 27

28 New Networks and Extend Existing Ones
5. Build Capacity: New Networks and Extend Existing Ones 5. Build Capacity: New Networks and Extend Existing Ones Federal and State agencies working together can: Provide backbone services for other participants to build their networks Provide process, monetary, policy, interoperable standards, and other support for these participants to get on the network Extend existing health and human services networks and infrastructure Coordinate across networks and improve data sharing and decrease redundancies HIE networks that will enable a unique unprecedented combination of public (federal and state), non-profit, commercial, and citizen networks to come together and get connected as part of one large integrated network to provide quality outcome based healthcare transformation

29 Open Source Innovation: Tapping into the “Wisdom of the Crowds”
A large group of people is better at solving complex problems than an expert, no matter how brilliant What are the implications for government?

30 Keys to Unlock the Kingdom
Unlocking information unleashes the power of networks to fulfill public services and discharge government duties. Governments can use IT tools to facilitate this result in five ways: Coordinating activities Synchronizing responses Enabling a single client view Sharing knowledge Measure performance

31 6. Networked Leadership:
Encourage Behaviors that Promote the Networked Approach Do Invest resources to ensure cultural alignment is achieved within your organization. Don’t Expect changes to happen overnight. Needs to address performance goals, position descriptions, core skills/competencies, etc.

32 Attributes of Highly Effective Network/Relationship Managers
Successful network managers have the ability to: Attributes Work across sector boundaries Develop and Manage Relationships & Strategy Identify the Network Participants Best Placed to Meet Goals Understand What Each Partner/ Stakeholder Needs in order to Perform Role in Network Thrive in Highly Fluid Environment with High levels of Discretion Embrace mission change from doer to enabler, from rowing to steering Recruit managers who can excel in this new environment

33 Key Principles to Create Networked Model
Define of Public Value Carefully Better Health, Not Better Transactions Design Network Correctly—Understand All Assets Quality Decision Making Congruence of Goals Build Skills and Capacity Network Leadership

34 A Change of Thinking Needed…
“People are very open minded about new things. As long as they are exactly like the old ones.” - Charles Kettering As government innovators try to use information technology to try to transform Byzantine, outmoded systems, they’ll face opposition from many fronts. Anybody who feels threatened by change is a potential opponent . As one CIO told me: “We discovered that technology was the least of the challenges. The bigger problems were turf battles, organizational problems and politics.” So how do you overcome the obstacles??? Afraid I’ve run out of time. Have to buy the book to find out.


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