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-Health2nd Annual State Learning ForumStephen GoldsmithDaniel Paul Professor of GovernmentDirector, Innovations in American Government ProgramHarvard University John F. Kennedy School of GovernmentDeveloped in conjunction with Deloitte Center of Health Solutions and Deloitte Research
2 Traditional Bureaucracy Is Inadequate Agency 1DivisionUnitAgency 2Agency 3DepartmentBureauCitizenIn 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 NGOsState GovernmentHealth ProviderLocal GovernmentCCID OrganizationInternational NGOsHospitalsWhile 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 governmentLevel of public/private collaborationOutsourcing 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 deliveryHierarchical governmentJoined up governmentLowLowNetwork mgt. CapabilitiesHigh
5 Information dissemination DEGREE OF GOVERNMENT INVOLVEMENT Types of NetworksSupply chainCivic switchboardInformation disseminationIntergovernmentalAd hocMoreDEGREE OF GOVERNMENT INVOLVEMENTLessService contractChannel partnership
6 Networked Organization Models that HIT Can Learn From Hurricane Katrina ResponseSARSEstablish that they required public-private partnershipsAnthrax Crisis Response
7 Governing by Network has Many Advantages… Improved Speed and flexibilitySpecializationNetworked government benefitsFlexibility. 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 reachInnovation
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 TOGETHERConnecting 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 groupsState 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” ofthe health information networkFederalNHINNational Health Information NetworkState HIEHI grant & Regional Center grantHIE grant – state gets it and then distributes fundsThe state builds upon existing networksRegional Center grant – support for the providers so that they can be part of the solutionBoth coming from ONC, total to 1.2 billion, grants publically announcedRHIORHIONetworkHealth NetworksNetworkHealth Networks
11 The Many Roles of Government States Can Play Many Roles in an HIE NetworkConvenerEducatorAdministratorPolicy MakerInitiator/ CatalystOperatorCoordinatorStates must lead the change.…in collaboration with health consortiums, citizens, payers, providers, and others.
12 Issues and Delivery Networks Possible Organizations Your RoleSchoolsRole of the Private SectorObesityMentalHealthLocal Non ProfitsNational FoundationsState HealthPolicy and FinanceInformation Sharing and IncentivesManaging the NetworkSector 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 SectorsPublic Hospital andCommunity HealthChild WelfareInfant MortalityInformationSharing Needs= Sector 1 = Sector 212
13 Key Principles to Create Networked Model Define of Public Value Carefully Better Health, Not Better TransactionsDesign Network Correctly—Understand All AssetsQuality Decision MakingCongruence of GoalsBuild Skills and CapacityNetwork Leadership
14 1. New Role for Government: Focus on Public Value Before:DC General HospitalAfter:DC Health Care Networks, From One to ManyInstead, 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 valueGovernment role: to transform existing social conditions in collectively desired directionsDemonstrations of value creation lie in evidence showing changes in conditionsProblem: Not everyone sees value in the same way
16 Different Ideas of Value Satisfy patient demandsProduce Better HealthReduce CostsMake a ProfitMeet Social NeedsAchieve a Just Society
17 Four Programmatic Areas Behind The Curve to Reduce Cost and Improve Care ConsumerismCoordination of CareComparative Effectiveness/Evidence-based MedicineHealthcare Information Technology
18 Examples of How Electronic Systems Drive Better Outcomes Care ManagementImprove care while managing costs, maximizing the health care investment.Care management, disease management, and utilization review.Electronic Health Records/Health Information ExchangeImprove 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 DiversionPrevent 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 AuditsDetect and correct errors and prevent future overpayments.Make better use of data to improve care to individuals.Nursing Home DiversionManage ongoing healthcare costs and provide care where it’s needed.
19 Pennsylvania NEDSS system 2. Design Network: Map Parties, Understand Tools2. Design Network: Map Parties, Understand ToolsPennsylvania NEDSS systemThe 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 NEDSPatient 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 resultsit works, has been around for 5-7 years; connects state, CDCS, labs, partners, all across the stateYou 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 GoalPA-NEDSS – An HIE Making a DifferenceLocal & State Health DepartmentsPatient Centric SystemHealth Information TechnologyPhysicians700+Privacy Centric & SecurePoint of Care Data EntryInvestigatorsHL7 based HIEEDR AppIntegrated Data Collection, Management, Analysis, Transmission, and DisseminationEpi-XRapid reporting and discussion of health events, 24/7 access to key officials and expert assistanceLinked Disease ReportsMoreCompletePatient ViewReal-timeDataCollectionMaster Patient IndexHospitalsPatient Search & Match400+MoreTimelyInterventionHealthAlertNetworkDOH Central OfficeDe-duplicationOTHER 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 RapidDetection Rapid Response EnablerLaboratoriesCDC170+20
21 Decide Who Should Do the Integrating 1SubcontractorGovernmentContractorSubcontractorSubcontractorContractorContractorGovernmentSubcontractorSubcontractorContractorSubcontractorSubcontractor2Prime ContractorSubcontractorGovernmentPrime ContractorOne 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:GovernmentA prime contractorA third partyIn 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 OTHERSKey thing is that this thought process needs to take place and be done carefully and systematically.3Third PartyPrivateProviderContractorSubcontractorGovernmentThird Party
22 Do Don’t Use multiple levers to build and activate networks Manage each network the same wayYour RoleRole of Other Government AgenciesRole of the Private SectorEducation and RhetoricMoneyManaging the NetworkInformation Sharing and IncentivesSector 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 SectorsRegulationsCapacity to ConveneSector ScaleInformationSharing Needs= Sector 1 = Sector 2
23 3. Quality Decision Making: Numerous Challenges Driving network governance vision down the organizationTraining and recruiting for the new skill sets (and cultural change) neededTreating partners as real partnersDeveloping and enforcing shared outcome goalsHorizontal management in a vertical governmentGovernment as 800 pound gorilla
24 4. Aligned Values and Incentives 4. Aligning Values and Incentives Congruence of Goals: Develop the Network Design4. Aligned Values and IncentivesCongruence of Goals: Develop the Network DesignWhatGoal of network?HowLevers used to initiate and sustain network?Type of network?Identify each parties goalsWhoPartners in the network?Who integrates network?
25 Share - Don’t offload risk Guidelines for Sharing RiskWhich 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 ExampleNearly 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 PracticesPublic 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 2010Financial support to State & Local HDsContracting agreementsExtramural researchBiosurveillanceNot so successful arrangements;NEDSSMonitor Performance26
27 A Life Cycle Approach to Performance Set Goals/Align ValuesStructureIncentives/Share RiskAchieving results from networksPREVENTATIVE:Particular to MEDICAID:CMS issued a letter at a 90/10 match to Medicaid agencies to implement health information exchangesNow 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)ManageChangeMeasure Network Performance27
28 New Networks and Extend Existing Ones 5. Build Capacity:New Networks and Extend Existing Ones5. Build Capacity:New Networks and Extend Existing OnesFederal and State agencies working together can:Provide backbone services for other participants to build their networksProvide process, monetary, policy, interoperable standards, and other support for these participants to get on the networkExtend existing health and human services networks and infrastructureCoordinate across networks and improve data sharing and decrease redundanciesHIE 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 brilliantWhat 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 activitiesSynchronizing responsesEnabling a single client viewSharing knowledgeMeasure performance
31 6. Networked Leadership: Encourage Behaviors that Promote the Networked ApproachDoInvest resources to ensure cultural alignment is achieved within your organization.Don’tExpect 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:AttributesWork acrosssector boundariesDevelop and ManageRelationships & StrategyIdentify the Network ParticipantsBest Placed to Meet GoalsUnderstand What Each Partner/Stakeholder Needs in order toPerform Role in NetworkThrive in Highly Fluid Environmentwith High levels of DiscretionEmbrace mission change fromdoer to enabler, from rowing to steeringRecruit managers who can excelin this new environment
33 Key Principles to Create Networked Model Define of Public Value Carefully Better Health, Not Better TransactionsDesign Network Correctly—Understand All AssetsQuality Decision MakingCongruence of GoalsBuild Skills and CapacityNetwork 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 KetteringAs 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.