At Penn Med, using software to cut health costs

See also my column in the June 12 Sunday Inquirer. -- Roy Rosin is Chief Innovation Officer at the University of Pennsylvania's $5 billion-a-year medical complex. It's not exactly R&D: Innovation there means cutting costs -- Rosin calls it "getting to better value and patient outcomes" -- by using software to save time and steps.

Rosin told me about what he and his colleagues are building -- doctors and profs from Penn's several schools, plus Penn health innovation chief David Asch, Independence Blue Cross innovation chief Tom Olenzak, and investors like DreamIt Health boss Steve Barsch (predecessor Elliott Menschik is now at Amazon -- including "Innovation Accelerator" experiments, "solving some of the big, intractable problems in healthcare delivery:"   

That's important because the federal government has expanded the breadth of health insurance subsidies, but also cut the reimbursement for procedures. If the old rates gave hospitals and doctors more than the cost of services, current commercial and Medicare rates are often way below cost and force you to economize. It means a therapy that keeps patients alive but needing care can create enormous expenses...

Dr. Thomasine Gorry, an Opthamologist and one of Penn's specialists with deep expertise in this arena, brought us this concept. She's a wonderful clinician, and a passionate innovator, in a group really intent on improving how we provide care.

What she and her team were able to demonstrate very quickly was that we can catch a high incidence of retinopathy -- and glaucoma -- by placing these cameras in primary care and... in labs where people go to get blood work done (for) specialty practices.

The cost of screening is lower, the patient experience is better with less discomfort, time and inconvenience and access is improved.

So what's the problem? In the old model, while screening costs were higher, we were reimbursed for more than our cost.  In the new, higher-value, lower-cost model – better for the patient in terms of outcome and experience, and better for the payer – teleretinal imaging reimbursement is far less than our costs.

We're working with our payer partners on this. But we have to figure out how make sure payments for novel interventions are fair and create incentives and financial support for delivering this care.

Does the pace of academics frustrate you, after a career at Intuit and in the private sector?

I want the health system to operator on a cadence like Silicon Valley cadence. That means iterations in days and weeks, instead of years. We are getting there.

And we've shown it's absolutely possible. In our Accelerator program, Dr. Schreiber and her team, working on the PEACE model for better care in the case of miscarriage, did 8 pilots in 90 days.

We had three things to prove:
Can we safely sort and route patients so those who should be in the emergency room (arrive) there or stay there?
Second, can I catch them and reroute them to the clinic (designed for an "improved experience" plus "cost savings") in time to avoid the costs associated with emergency room or operating room care?
Third, is it economically viable to do this? 

So it worked. It worked insanely well. The team working on this has now seen interest in establishing this team design, including (from) Pennsylvania Hopsital. That's what we look for -- reproducible results.

We love these fast experiments. The goal is scaled impact... 

Anna Doubenis is a family medicine practicioner and professor. She led another of the Innovation Accelerator projects focused on "super utilizers," the 1% of people who account for 30% of costs. On her initial, small-scale, high-touch model, she showed a 42% drop in Emergency Department utilization.

The major determinant of health is (often) not a medical thing. (They may have symptoms of illness) because they are depressed. Because they have food insecurity. Because they are being abused. Because they have addiction issues.
 
The stories that come from Shreya's group, they are mind boggling. A woman whose son was incarcerated, once released, became her major concern. So helping situate him was teh most important first step in helping her begin to take care of her own health.

A man who wasn't taking his medications -- why? He had been a musician earlier in life. Shreya's group was able to reconnect him to that passion. Once he was engaged in life they were able to work on his health needs...

You see, the key wasn't patient education, or reminders to take your medicine or go to your appointments. It's, 'what's the root of this problem?'

They got to the bottom of that. It was work on human motivation. These are such complicated things.

There was a woman who was a super utilizer. A 'Frequent Flyer.' This group got her to open up. She was being abused by the landlord. He was stealing her checks. They had to get her set up with safe housing. All of a sudden her health improved.

The root cause is different from what we think.

Dr. Anna Doubeni, the family medicine practicioner -- she does house visits -- her super-utilizer program is making progress. She is looking at multi-factorial problems. There is no way to have good health if you are homeless. You can't keep your meds cold, for example.

Big problem was not knowing who needed attention, who had increasing problems and needs, who started showing up more frequently in the emergency room.

Dr. Shreya Kangovi, her program is called IMPaCT, she has this Penn Center for Community Health Workers. 500 programs have downloaded Impact. It's  becoming a national model.

And there's a DreamIt company, Keriton, they came through the Penn Apps Hackathon, which (Penn Center for Innovation COO) Laurie Actman (CORRECTED) helped set up to connect academic guys with real world advisors...

Lactation nurses in the HUP NICU needed some way to track and measure breast milk -- pumping too much, or too little, are both problems. It turns out that the inventory management of mother's milk takes thousands of hours for nurses -- who while they're doing it can't do patient care.

Laurie Actman from Penn's Center for Innovation and I connected clinicians who had real-world problems they were trying to solve with the engineers participating in the Hackathon.

So they gave the program remote sensing. Sensors that can measure and tell you how much has been pumped and how often the woman is pumping. Bottles and labels that can be tracked with hands-free scanning, so checking in multiple bottles takes a fraction of the usual time and effort.

Automated inventory management -- that means we know when we're running low, that the right baby always receives the right milk, and that the baby never receives expired milk.

Penn has this interesting advantage: Everything is on one campus. At Harvard the medical school is in Boston, the business school is across the river, the engineers are down over there. Penn is totally different. You can walk there.

Our work with Sarah Rottenberg in the Design School's (Integrated Product Design) program means that every year talented designers tackle real health system problems.

We partner with Chris Murphy, a computer scientist at the Engineering School, as his students are also looking for important, real-world problems, and they bring programming skills that can turn ideas into prototypes quickly.

It doesn't work all the time. I can't say the success rate is 100%. We have done dozens of projects. We have maybe a 60-70% hit rate. 

I love this generation. They want to improve the world. It's the concept of repair the world. (Tikkun olam. Or St. Francis.) That is their attitude. They have gotten to this point: 'I don't want to work on the next Facebook. I want to solve a real problem.'

Silicon Valley uses a lot of quick-and-dirty techniques to help focus product development... 

I'm not trying to prove anything scientifically, at first. I am experimenting anecdotally. And when you do that, all of a sudden you start to have data, evidence and insights based on reality, not an abstract concept, theoretical strategy, or a PowerPoint.

Nudges use techniques of choice architecture and other insights from cognitive sciences to help move people to making better decisions and choices.

One of my favorite examples from his work includes an intervention where he worked with our IS team and our chief medical information officer, Dr. Bill Hanson, to make generic medications the default in our emergency room.

Use of generics not only lowers costs to drive higher value care, but also, due to affordability supports higher medication adherence.

We saw an immediate and dramatic impact shifting towards appropriate prescriptions of generic medications based on this work.

Some of his latest work revealing intervention designs that best promote physical activity is a good example of where rapid experiments can accelerate and support but not replace gold standard research methods like randomized controlled trials, RCTs.

When I came here I looked at all the great work Kevin Volpp, David Asch, Mitesh and other faculty in CHIBE were leading, applying behavior change insights to healthcare delivery.

I wondered if some of their insights – including the power of social support – could be used to promote physical activity.

In the mode of fast experimentation I structured a competition where we organized teams of four to get accelerometer apps on their phones and compete in terms of daily steps taken by the team.

Every enterprise has a wellness program. We suspected they weren't optimally designed, especially as the incentive designs are not based on evidence and CHIBE faculty's work was revealing that incentive designs really matter.

When companies have walking competitions, traditional programs are designed so employees with the most steps win.

I played around with that. We ran some fast experiments. We were able to quickly demonstrate some interesting insights in the effects ofteam structures (team interactions promoted increased activity) and incentive designs.

Pretty quickly it started looking like 'most steps win' designs just made active people superactive But it also just makes sedentary people discouraged.

So what do you do to improve your real target, the more sedentary people?

Mitesh took it from there and generated new interventions using more rigorous methods... The quick and dirty initial work meant that once you get to the more in-depth, expensive, scientific testing you can avoid wasting time and money on interventions that have no anecdotal support and focus on those where there's some reason to believe they might be worth (following up with in-depth research.)

Mitesh's work has appeared everywhere from the leading peer-reviewed medical journals to the Today Show. He does great research.