"Prescription for the Future"

Ezekiel Emanuel is an oncologist, bioethicist, and health policy researcher who currently serves as the Vice Provost for Global Initiatives and Chair, Department of Medical Ethics and Health Policy at the University of Pennsylvania.  Dr. Emanuel has written extensively about our U.S. health care system, and he served as one of former President Barack Obama's chief advisors and architects of the Affordable Care Act in 2010.  Incidentally, he is also the older brother of Rahm Emanuel, President Obama's Chief of Staff from 2009 to 2010 and former mayor of the city of Chicago.  This past year, I read his most recent book, Prescription for the Future, in which he lays out twelve key practices that he believes will transform health care for the future.


Dr. Emanuel starts off his introduction with the prophetic statement, "With the electoral victory of President Donald Trump, it seems reasonable to ask whether this book is still relevant.  Have current events overtaken a book advocating reform and transformation of the American healthcare system?"  His answer is a resounding no.  He goes on to say, "Improving the American healthcare system is something every patient, every small business owner, every corporate executive, every physician, nurse, and other practitioner, every politician and policy-maker should care about.  The system desperately needs to be fixed."


He starts off by suggesting that there are six essential elements that will be necessary for the successful transformation of our healthcare system:


1. Catalyzing crisis - According to Newton's First Law of Motion, a body at rest will remain at rest unless acted upon by some external force.  Similarly, there has to be what John Kotter calls "a sense of urgency" for people (and organizations) to change.  Without some external force applied to healthcare, there will simply be no change for the better.


2. Leadership - Again, take one look at Kotter's classic 8-step change model and it is clear that without someone serving as the driving force (the catalyst above necessary to overcome inertia) to create the "sense of urgency", "build a guiding coalition," and "form a strategic vision", it will be next to impossible to change the healthcare system for the better.


3. Culture, Governance, and Physician Engagement - You have probably heard the old adage, "Culture eats strategy for lunch."  It's absolutely true - without the proper culture, change will be next to impossible.  Similarly, having physicians engaged with any change initiative will be absolutely essential.


4. Data - Dr. Emanuel suggests that at least 5 types of data will be necessary for healthcare organizations to successfully implement his 12 transformational practices (1) claims data, (2) laboratory data, (3) imaging data, (4) pharmacy data, and (5) clinical data.  Clearly, having the right data will be necessary to identify quality gaps and drive improvement.  Having the right data analytics is even more important - data scientists should be involved at the beginning of any change initiative to help design valid, reproducible, and measurable metrics for improvement.


5. Physician management/alignment - I have argued this point as well - having physicians aligned with management, or in many cases, serving as management, will be a key aspect of the drive to change the American healthcare system.  Several organizations have adopted the concept of leadership dyads and triads (physicians leaders, nurse leaders, and administrators work together to create the necessary alignment and collaboration for change).


6. Financial Risk and Incentives - If the financial incentives to change the system aren't there, change will never happen.  If health insurance companies aren't "all in" with creating the necessary incentives for organizations to change, transformation will be dead in the water.


Dr. Emanuel then follows these six essential elements with 12 transformational practices that he has observed in highly successful healthcare organizations and which he believes will be necessary to transform the U.S. healthcare system.  Importantly, he doesn't provide any significant description on (1) how to implement these practices or (2) how to pay for them, but I do think these practices represent a reasonable starting point for change:


1. Scheduling - Particularly with respect to clinic visits, open access to scheduling (where the patient can go online and schedule his or her appointment) has decreased utilization of high-cost sites of care, such as the Emergency Department (with subsequent decreases in cost) and dramatically improved the patient experience.


2. Registration and Rooming - Improve the efficiency of the patient registration process (if you've ever been to a doctor's office or required admission to the hospital, you know exactly what this process entails) and have medical assistants rather than nurses room patients (bring the patient back to the clinic office).


3. Performance Measurement and Reporting - establish key metrics - preferably ones based on outcomes and cost of care - to drive improvement.  Link these metrics with performance evaluations and reimbursement.


4.  Standardization of Care - Standardization of care is not "cookbook medicine" - it improves the efficiency and cost of care, as well as both the provider's and patient's experience with care.


5. Chronic Care Coordination - We need to shift from an Acute Care-based model to one that emphasizes care management of chronic diseases, which disproportionately determine the overall cost of care in the United States.


6. Shared decisionmaking - Patients should be involved in making the decisions about what care they receive and how that care is delivered.


7. Site of Service - Patients should receive care at the right place and the right time.  As one example, the emergency department should not be used for routine or non-emergent conditions.


8. De-institutionalization - Again, we need to shift from an acute care-based system to one focusing on health and prevention.


9. Behavioral Health Interventions - Mental health has been neglected for far too long - we need to make the right investments to improve the overall physical, spiritual, and mental health and wellbeing of our patients.


10. Palliative Care - We need to invest in palliative care, so that patients who are in the final stages of their life can be cared for at home, if they choose, rather than in the hospital setting.


11. Community Interventions - Health care organizations should start focusing on the health of their local populations. 


12. Lifestyle Interventions - Again, addressing the social determinants of health with a renewed and re-energized focus on lifestyle factors (exercise, diet, tobacco use, etc) will be necessary to drive improvements in key health metrics such as life expectancy and infant mortality, among many others.


Overall, I really enjoyed Dr. Emanuel's book.  I do think his recommendations make a lot of sense.  He focuses mostly on the "what" and perhaps falls a little short on the "how", but the book is definitely worth a read.