Health 2.0: Exclusive Interview with James Madara, EVP and CEO of the American Medical Association

Dr. James Madara, EVP & CEO of the American Medical Association (AMA), provides perspective on how digital health will be integrated into health care systems. Matthew Holt, Co-Chairman of Health 2.0, had an opportunity to personally chat with Dr. Madara and find out what the AMA is up to now!

See AMA’s CEO and Executive Vice President James Madara at the 9th Annual Health 2.0 Fall Conference speaking about how to fix the clinical user experience. To attend the Health 2.0 conference, register here.

Matthew Holt: James Madara is the CEO of the American Medical Association, which he’s been for about four years now. Before that Jim, you were head of the University of Chicago Medical School. So, you know what it’s like to run a large, complex, and probably dysfunctional organization, I suspect!

Jim Madara: Well, they are very complex organizations and I have always been a complexity junky, so it satisfies me in both ways. But the AMA is really focused on the health of the nation and we began a long-term strategic plan about two-and-a-half years ago. The three elements of that plan, I would say, give insights on how we are thinking about technology in the future.

One is changing the structure of medical education as it occurs in medical school to update it. The curriculum is always updated with new information each year, but the basic structure has been in place for a century, even though a lot of other things are starting to change.

Team-based practices as opposed to individual attention and thinking more in the clinical domain about the shift toward chronic rather than acute disease results in the need for substantial outpatient exposures, working on continuity of care, working on those handoffs and the like. So toward that end, we have 11 schools, including UCSF, that are participating in this learning consortium. Each school is bringing a piece of innovation to the program. One can start seeing the medical school of the future and how that might look.

Technology is also going to be an important factor, as what used to be dominant inpatient exposure moves to dominant outpatient exposure. There was also a fair amount in the future of home care delivered through telehealth and other technology venues that will be important in shaping these health care providers, the physicians for the future. Another area of technology is the digital kinds of learning that can occur currently.

Another area is thinking about the delivery of clinical care, and working to understand physicians’ practice and initiatives that could enhance practice efficiency, professionalism, satisfaction, and delivery of care. First, we worked to identify a foundation of understanding and there we partnered with RAND and we’ve done two collaborative studies. The first released in October I believe, and that study focused on dissatisfiers and satisfiers in practice for physicians.

The high-level message was that the dominant satisfier was essentially a single thing. It was having sufficient time with patients to feel that one has really had a time to interact, and at the end of the day provide high-level care, and so the dissatisfiers are all the things that have got in the way of that.

Some of those were intrinsic to the practice. We have precisely defined a panel of those and we released a digital and engaging set of tools called “Steps Forward” and released those the week before the last. That will take physicians through how one can better organize previsit planning, for example. So that when a patient comes to an office or interacts with the physician, there is an understood agenda of what the patient wants to get accomplished with the testing done. Then, at point of interaction there can be a fair amount of collaborative planning for next steps.

The electronic health record was a large extrinsic dissatisfier. It’s certainly an advance. No one wants to go back to order forms, but the electronic health records of today are optimized more for claims, billing, and medication – not so good at the entry or extraction of clinical data needed at the point of care. So we are working with both vendors and regulators toward that and improving that piece of technology that is crucial but awfully clunky right now.

And then, the third element is very patient-oriented. The third area of focus is thinking about chronic disease. We moved from acute disease to dominantly chronic disease in the last half century, which means that the disease plays out in the community rather than in front of the provider. As a consequence of that, we need to think about how one uses community assets for help with chronic disease and then connects that back in the health system in a meaningful and efficient way.

The problem we picked is prediabetes. We’re working with tools that prevent the conversion of prediabetes to diabetes. Over 80 million Americans are prediabetic, and only 10% of them know it. Those 10% that know are quite sure what to do, the other 90% do not even know.

The tools we are deploying are effective at preventing the conversion to diabetes and we also have some usual partners- like Centers for Disease Control. But also some unusual ones. The YMCAs of America are one of the sites at which the program connects to. Figuring out to use pre-diabetes as a model, how one can start thinking about chronic disease in society differently, utilizing community assets and then connecting that back to the health system. That is going to be very important because 75% of our health care spend– CDC estimates more than that actually–is tied up with these chronic diseases.

Those are the three areas and technology touches each of those three areas.

MH: But essentially, those are the three major problems of the U.S. health care system – so what you’re trying is a BHAG! Big Hairy Audacious Goal.

We are moving, as you said, from an individual to a team based sport. If we move to a team based sport, we should have better technology which should actually allow more monitoring of patients who don’t need to be in the office and give doctors more time with patients who do need their help and extend the time that the doctors get to spend with patients.

You hear great stuff about what the future of health care delivery might look like. But clearly, from your research and from Bob Wachter’s book, there are many other ways we could look at it. What’s actually going on now in this change in the way care system is delivered, with the doctor in the exam room. It’s not in a state of hour long visits where the patients and the doctors are fully engaged in their conversation. There are a lot of other things getting in the way.

So, how realistic are these new visions of care and how far on the way are we to getting there? Or do you think we’re taking steps backwards now before we take steps forward? 

JM: Well, so for example, if one has systematic prescription writing in an office, we have a module instructing people how to do that, taking them through that in an interactive way, so that someone who is on three drugs does not have three different asynchronous prescriptions that are renewed throughout the year but rather one 13-month prescription. That shift alone saves an hour to an-hour-and-a-half of physicians’ time per day.

I think there are two approaches. One is an approach of trying to solve some of the complexity that has been layered on physicians’ offices and that’s the steps forward kind of approach, those modules and tools. The second is we try to bring in more practical knowledge to tools as they were developing.

I will give two examples of that. One is that we convened a diverse group, just a week or two ago, to talk about whether there should be principles or guide rails on mobile health devices. What I mean by that is, what kinds of devices are actually needed and wanted and useful, and how can that data be assembled in such a way that it’s actually useful in the medical system.

It surprises some people to hear that you can digitally monitor 24/7 some biological product of your body. But that data times 2,000 [across a] patient panel is probably not going to be very useful for the provider unless it’s reduced to a useful, actionable, small data set. We’re also, for example, interacting with [technology startups via] a partnership with a health care startup hub here in Chicago called MATTER. MATTER was just launched a couple months ago, and has about 85 companies.

What we are doing with folks in MATTER is bringing in a more granular understanding of say, how a physician-patient interface works or it doesn’t work, what its needs are, etcetera. So that when products are developed, they don’t come over the transom kind of 20 degrees off of what could have been optimal.

I think one of the things that the industry sometimes lacks is a very deep granular understanding in how things flow, how events happen. What happens at the physician-patient interface? That can inform, enrich, improve, and optimize products. I think you can take the approach as somewhat defensive and that we have these problems, how can we increase efficiency in the context of these problems, such as our Steps Forward approach. We can take a more offensive, proactive approach of, “Let’s make sure that those developing the technologies of the future understand the health care needs in a very granular way so the products can be more optimized.”

MH: That’s a great idea and I think funnily enough, we’ve been coming at it from a slightly different angle which is, looking at the role of designers and developers and trying to put them together–we run a conference called HxRefactored about that.

It’s true that most of the large electronic medical record vendors and other players are now adding designers and user experienced people to their teams — but just doing it now. We’ve been putting in these EMRs for the last few years and we’ve been really putting in not the greatest and latest technology.

Let me ask a related question which goes back to my idea of what the ideal dream would be. You hear a lot about team-based care and a technology that would deliver the right information from patients when they’re not in the office.

We’re also hearing a lot about new organizations which have been structured to both manage the financial reality of paying for value other than paying for volume but are changing the complexity of how everyday physicians have been organized in this country for many years. Obviously, I’m talking about the kind of care organizations and physician practices being purchased by hospitals. Many more physicians are being becoming employees of hospitals and other organizations like that.

How do you think, that in general, that change is going and how much does it impact the AMA and where you stand on that. I think when we hear a lot about physicians being dissatisfied, a lot of that comes from the new types of questions coming from these new types of organizations.

But obviously, we have different workforce, more female, less prepared to do what perhaps was required back in the day, to run their own practice and that kind of stuff. What are your thoughts about where we are in the transition of how the workforce is compiled to work out for this new type of care?

JM: AMA and RAND collaborated on a subsequent study too that was released more recently. It studied physicians’ attitudes, states of satisfaction to satisfaction and the like, in the situation where they were moving from one delivery model to another so, we could learn more about that. It is interesting that some of the larger models, ACOs and the like will feel at the top as though it’s value-oriented because that’s how the financial model flows.

It actually doesn’t penetrate too often to positions that are more evaluated on their productivity. So it’s more of a fee-for-service still down on the ground, although on the institutional level it’s value-based. So that’s an interesting dynamic.

The other interesting thing that we’ve learned is that there is a tsunami of quality measures now, and AMA produced about half the quality measures for CMS, and we have gone through this phase where it was important that we think about health care as something that had components that one can measure, and so we got this idea of measurement into the system. But now we have literally thousands of these things but some of them that have been accepted by payers don’t have a great evidence base. Some of them are great, some of them are outcomes, some of them are process, some of the have an evidence base, some of them don’t.

And what we found in some of the large organizations is that they will take the penalty and ignore a set of measures, but then what they do independently is they assemble a set of measures that the physicians believe and that are important to their particular practices. So physicians want to measure, but they want to be able to believe that what they’re measuring is important. And I actually have a view point on this and in a recent JAMA article around the incentives. I think we got the incentives all wrong. We’ve structured incentives as the Chicago school might have, straight economics, trying to change people’s behavior with small penalties and small rewards.

We have not structured it in a way that behavioral economics would recognize. And I think the more behaviorists, would suggest that in complex cognitive task, you want to find out what the intrinsic drivers of behavior and motivation are. And Jonathan Kolstad, who is at Wharton, published in the American Economic Review a paper that gets to the heart of this. I think in medicine, it was two groups of cardiovascular surgeons. One group was told that they would get a financial reward for improving a quality measure. It was readmissions sort of some such thing.

In the other group, quality was not discussed but it was known that they wanted, like other physicians, to have real-time actionable data comparing their practices with others. The real-time data actually was four times the incentive than the financial incentive was in terms of increasing quality. So I think that when in our own studies with RAND, the first RAND studies revealed this too, that what motivates physicians is a productive interaction with their patients.

And so in terms of incentivizing physicians to produce value, I think you want to push on the intrinsic motivators, free up their time by making their practices more efficient so they can get this higher-level thing that they want, a time with patients and give them measures that they actually believe in.

Another strong message that came out in the second study was the importance for an organization like an ACO if let’s say, it’s a hospital-led ACO. An important aspect of that organization working efficiently is having values aligned between management and physicians. And once you get those values aligned and shared, you get a much more effective working relationship. We in fact partnered with the American Hospital Association, and are just about to release a paper of principles of how hospitals and physicians can have these shared values and how do you get there, and what are the components of that.

I think one thing that’s not going to happen is we’re not going to move to one model. I mean this is the United States. We do everything in the most complex way possible. We’re going to have public and private, we already decided that. And the needs of Manhattan, Kansas, are very different than the needs of Manhattan, New York. So we will have a variety of models which shift to more of a value-based reimbursement.

MH: So we’re running over time, Jim, but if I could ask you a last question, and at the conference we’ll talk more about the usability of the tools and the technology for this. I’d like you to elaborate on what the practice for a typical physician would look like, when (and if)  if we get it right on the incentive side and in the organization side and the mastery of craft side and the satisfaction side.

What do you say the end state would be, and what do you think the role of AMA is to help promote that?

JM: Sure. Well, I think you know a person trained in the medical school of tomorrow, will have some skill sets that are already developed when they enter practice that we don’t do a good job of installing now. So for example, practice management science. In a complex team-based care environment, how does one continuously improve and become efficient so one can free time to interact with patients?

I think that there will be a lot of telemedicine interacting with patients, and many people will be able to have what would have been a physical visit satisfied through telemedicine, and that telemedicine interaction may also include patient’s queries about data that they have generated from implantables, wearables, other things that they have. It will be important that we get through the phase of knowing how to convert big data to small data, not only from the devices that I mentioned but importantly, from the electronic health records. How do you get organized to clinically meaningful, actionable data at the point of care, and how do also become much better through natural language processing and other kinds of approaches of getting physicians away from those terrible keyboards that they hate.

Many physicians feel they have the choice of ignoring a patient or not doing what they are required to do for the electronic record–the computer gets vastly in the way. I think we’re going to have much more outpatient in the home as well, but even outpatient clinics. If you looked at what we have done with cardiovascular disease and stroke in the last 30 years, converting what would have been certain deaths into more chronic but manageable diseases.

And if the evidence is that is where we are going to probably end up with a large portion of cancers as well. They’ll be chronically manageable. So again, the idea is much more enriched outpatient and earlier diagnosis prevention management, and also that means that you’d have much better continuity principles, where patients do have their data, where you have electronic health records that actually speak one to another.

And I think the AMA is going there. We’ll continue to be a respected convener of diverse interests, fostering these interactions. Many people misunderstand the AMA just as a membership organization. A quarter or so of physicians belong currently and that’s — I am happy to say has increased over the last four years each year, but it also functions as an organization of organizations.

So the body that creates the policies for the AMA are all the specialty  & state societies in the country. We have 185 societies in our house of delegates, every state all the societies you would have heard of like the American College of Cardiology and those that I am sure you are unaware of like the Society of Underwater Medicine, which is my personal favorite.

It is all those societies that linked to every physician in the United States, most physicians belong to more than one those societies from which our policy emerges. We have this convening role in the three areas I mentioned. We have the doing role, and we’ll also take problems that we define through the art of doing through partnerships. For example, in the three areas that I mentioned, and have a role in creation through design and prototyping and production of products and services ourselves just the recent steps forward product.

MH: Yeah. I think that’s great and very helpful. As I said, from the start you’re dealing with  this complex organization but also one that is prominent in the incredibly large and incredibly complex system which is the health care system.  As you said, we’re not going to change it in one way straight away. But obviously with a lot of technology, the whole organization will change, education will change, not to mention the changing role of patient. There is so much going on, it’s a fascinating journey. 

I’ve been talking with Jim Madara, CEO of the American Medical Association, and we look forward to seeing Jim, who will be chatting with me at Health 2.0 this October, on a panel looking at the clinician user experience.  So Jim, thank you very much for your time today.

 

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