George Halvorson HIMSS Changemaker Lifetime Achievement Award Acceptance Speech
August 4, 2021
Thank you for giving me this first ever HIMSS Changemaker In Health Care Lifetime Achievement Award.
You are honoring an extremely impressive set of other current changemakers at this particular national meeting for 2021 and I am very honored and pleased to be the first person to be given the Lifetime Achievement version of this Changemaker award.
Changemaking is a good thing.
Changemaking is actually happening at a massive level for health care systems right now and that is good for health care and it is good for health care patients.
We are actually at the dawn of a golden age for health care systems, and I deeply appreciate being recognized for having done several fun, useful, and interesting things over time to help get us to where we are now.
As you pointed out, I have personally had a chance to work very directly on rolling out full electronic medical record systems in a couple of real and functional care systems to tens of millions of people.
It worked well.
We ended up with care sites in those settings that literally had no internal paper flows and that had and still have instantly available medical information for thousands of caregivers about their patients.
That tool kit worked extremely well.
Those care sites ended up with the highest ratings in the country for both quality of care and service and that high level of performance happened because the sites had both a culture of continuous improvement in their care settings and the highest levels of continuously available data for the caregivers in those sites about the patients they served.
That was a mantra, a goal, and a strategy — and it became an actual functional capability.
Having All of the information about All the patients All the time — All-All-All is a good mantra, an extremely practical goal, an extremely functional strategy, and a very solid working practice for the delivery of care — and that data strategy worked even better than we had hoped it would work when we started down that path.
Having full electronic data on every patient improved diabetic care, chronic heart disease care, and stroke and heart damage prevention — and it created major reductions in the complications of care for chronic care patients in every category of care in all of those settings.
The data about patients was expanded at Kaiser Permanente to be the first major site and system in the world to add race and ethnicity to the care data for millions of patients.
That turned out to be extremely useful information. Having continuous use of comparative data on care-site performance by race and by ethnicity, as well as by the other measures of patient status, helped reduce cancer deaths, prevented both strokes and adverse heart effects, reduced chronic care complications, and allowed for focus of care efforts by care site and by patient in ways that continue to improve today in those care settings — because the approach is built into the culture of care in those sites as well as into the tool kits used there for the care.
The goal was to have electronic data on every patient and to use that data to significantly improve care in continuously improving ways.
That goal was met — and that success tells us that other care sites in the world should go down similar paths for both complete electronic access to care data and for using that data for the care sites to continuously improve their performance and processes.
That cost a lot of money — but it was fully worth the investment. The billions of dollars spent putting that system in place were repaid in full almost annually by the improvements in both service and care that were enabled by that data and by those systems.
So, from a lifetime achievement perspective at this conference, I am delighted to tell you that set of work was positive and it proved that system-supported care is beyond any doubt the right way for care to be delivered.
But that’s just the start.
What I want to tell you here at HIMSS today is that success is just the tip of the iceberg, and the future is actually going to be even better at multiple levels for both the tool kit and for the delivery of care.
We can do almost magical things at this point if we use the new tool kit at the most effective and optimal levels.
We have the chance to do some important additional things really well because we now know what those additional things are and we know how to put them in place.
We are on the cusp of a golden age for systems-supported care.
Every patient now has electronic data somewhere. That electronic data that now exists at some level for every patient now needs to be connected in ways that benefit both the caregivers and the patients in every setting.
The technology is there.
We are better than we ever were at building linkages in the systems world in every other industry. Care is now ready to be connected as well.
Full data sets for each patient that can now be created by FIHR and by other connectivity tools will enable and support team care along the lines created and enabled by the patient-centered medical homes model and by similar Accountable Care Organization models and processes for improving care.
Oncology medical homes and oncology care enhancement movements and alignments will definitely happen and they should thrive because the care improvement and connectivity opportunity is so huge and so desperately needed by so many cancer patients everywhere.
The difference in cancer care success levels between sites is very high and we need the public to have that information in the future to help patients make cancer care choices — and we definitely need to have the caregivers in the underperforming sites improve their care.
Artificial Intelligence (AI) will do magic all by itself in several areas of care.
AI is just beginning to have the huge impact it will have on care. AI will do almost magical things in some areas now — and that scope and that magic will expand very quickly across multiple levels of care.
We get care wrong much too often today. Misdiagnosis and very slow diagnosis and incomplete and inaccurate diagnosis happen for too many patients for too many conditions today.
The new systems tool kits that you are all building right now will help hugely in those areas.
The death rates we still have in this country from too many current misdiagnosis will be cut very quickly by more than half with the new analysis tools, and the caregivers will also all have continuously improving access to current care science and to continuously improving care protocols and care approaches that will double the effectiveness and continuously improve many patterns of care.
Patients will be able to have real time access to their own electronic care data at a functional level if we go down the right paths at this point in time as a buyer of care — and patients will value, treasure, enjoy, and personally use that data both in their current care sites and with the thousands of personal care-related apps that will be offered on the internet to help patients track, enhance, evaluate, support, and understand their own care.
Paper files are finally gone.
Care information for all patients will be on someone’s electronic medical files, and we need both the caregivers and their supportive care plans to have that information in real time to deliver and improve care and to make it available to patients in the ways that patients want that care data to be available.
That will definitely save money.
Care should cost less when we get it right.
Care should cost significantly less when we reduce the number of diabetic complications by half or more and when we have better and faster cancer diagnosis using genetic data more widely to figure out patient specific care plans that will reduce inpatient stays, complications, and death rates for patients with cancer.
Multiple new tools will allow us to detect many cancers much earlier.
And the new tools will anticipate cancer growth at the most opportune time for us to change the trajectory of each cancer case in highly beneficial ways.
We will be able to use links like Fitbit data electrocardiograms to have a much higher level of success in both preventing adverse events and responding to them at the most opportune time in ways that optimize successful outcomes.
We will have multiple sites for care — including the home — and that is relevant to you because your teams of people will need to support them all.
The home will be extremely well wired for delivering many levels of detection, monitoring, and directly delivering care. We are already beginning to see some care systems who are actually delivering the equivalent of inpatient hospital care in people’s homes and doing it with extremely high levels of quality and success. That set of patterns and that approach to in-home care will grow and it will continuously improve.
The old Kaiser Permanente systems macro strategy that we put in place when we launched the first electronic medical records for our patients and invested the first $4 billion on that trajectory said very explicitly that the future would actually be based on five sites of care — with homes as one of those five key sites of care.
The five sites of care that were built into that original Kaiser Permanente systems support plan were the doctor’s or caregiver’s physical office, the hospital, other short- and long-range inpatient settings, people’s homes, and the Internet.
The Internet links to care were almost non-existent when that five-site strategy was kicked off and put in place at KP — and that has exploded to the point where over 60 percent of the patient visits in that particular care system in this current Covid year were electronic.
That’s a very good tool kit. Patients and caregivers both like it a lot.
Patients actually prefer electronic care links for many components of care, and we can expect to see that set of electronic linkages to patients grow in vast numbers of care sites across the country and across the world.
We really are at the cusp of a golden age for care today as I accept this Lifetime Achievement award. We will have better diagnosis, better and more accessible treatment, and continuously improving processes and systems at all levels, and we will spend less money on care when we get it right because we now know for a fact that better care costs much less than bad care, less than delayed care, much less than functionally uncoordinated care, and less than inadequate and dysfunctional care.
We also initially have an important and continuously improving sense of the epigenetic processes that exist in all of us to develop our own responses to the world we are in at a biological level, and we should be able to use that information to improve our health and our care.
That is extremely relevant to you because it is very much a systems and coding issue to bring epigenetics into care delivery and care systems.
The magnificent, wonderful, and extremely powerful new CRISPR tool kit actually used computer like coding approaches and created a vaccine for Covid that explicitly triggered our body’s immune responses exactly as our epigenetics are naturally programmed and coded to do for other vaccine approaches.
We will be able to use that set of tools to improve our responses to cancer and multiple other diseases in a growing variety of important ways. We actually now can choose to evolve as a species because that particular tool actually allows us to change our genetic code in very channeled and intentional ways. That capability and reality is hugely important — and we will now be able to use those new tools in a growing range of ways.
We should be able to stabilize or reduce the amount of money we spend on care when we put these full sets of tools in place.
However — we also do need to become better and smarter buyers of care to make that full set of enhancements happen.
Every economic system on the planet does what it is paid to do. Care is not an exception to that reality.
That full connectivity level and organized team care for patients will only happen if we decide as a nation to stop buying all care by the piece — and if we move to paying for total care for our patients to teams of appropriately supported caregivers who are rewarded financially for continuous improvement.
Care sites everywhere in the world do what they are paid to do. They also do not do things they are not paid to do. They function as businesses everywhere, so they do what every business does in every industry and they give their customer exactly what the customer pays for.
No business in any industry uses any other model.
With that reality in mind — we all need to understand the fact that we Americans buy care very badly.
We actually have the most primitive payment model in the world for most of our care — because we only pay for most care by the piece and because the functional reality is that buying care only by the piece actually rewards bad care and it rewards care failures because care failures create more pieces of care, and that creates high levels of cash flow for business sites for care in our country.
We spent trillions of dollars on care and the approach we use now rewards bad outcomes and the way we buy care actually does not pay caregivers more when care gets better.
It creates tons of cash flow and it triggers growing profits when care is bad.
Think about what that would mean if we used it in any other industry.
The car industry would probably function very differently in the design of cars if the people who bought cars had to pay twice as much to the car builder when the car crashed, and if the people who bought cars had to pay double to the car builder when they died in a car accident.
Think about it. Would you want to fly on an airline if the airline company actually got to double the fee if they took you to the wrong airport?
Some people in politics and in our government strongly support that piece-work purchasing model for care in our country, but tend to do it for sadly dysfunctional and for very poorly informed reasons.
Our politics tend to reinforce that bad piece-work purchasing model that triggers trillions of dollars in cash flow to care sites — and most people in those settings don’t even know that is happening or understand that any alternative ways of buying care exist.
Politics on both sides of the aisle has created and sustained much of that problem of buying care only by the piece. Our current caregivers who literally receive trillions of dollars in cash flow for all those care deficiencies and care delivery flaws have people in both political parties who strongly and sometimes fiercely resist any models of payment that can actually create accountability or improve care.
Classic Medicare fee-for-service payment does not have one single quality standard because it is far too hard to measure quality when you only pay by the piece. Medicare Advantage has a couple dozen quality measures and even pays slightly more when quality is better, but standard Medicare fee-for-service does not have a single measurement — much less any quality incentives for any piece of care.
Too many insurance models echo the Medicare approach.
We could transform that entire system and we could get immediate access to better and to continuously improving care if we just started buying care with clearly designed purchasing expectation specifications by the patient as a package and not by the piece — and then imposed incredibly, continuously improving, and well-designed performance expectations about team care, about brilliant diagnosis, and about major reductions in care deficiencies to the expectations for the product.
We need to very intentionally become a competent buyer of care — not just a dysfunctional cash-rich direct payer for care with no specifications or expectations for the actual care that is paid for.
We need to buy care better to have all of those wonderful new systems and tools used on our patients. You know exactly what the problems are — because many people in this room support those care sites now.
So let’s do better.
Buying care by the month for each patient instead of by the piece transforms that cash flow deficiency — but the people who do our health care policies for both parties in every state tend to favor approaches that do not make actual care improvement a goal or a priority, because the current massive cash flow for care goes to people who support them in maintaining that approach.
So we spend more than anyone in the world on care by a wide margin, and we get poor and uncoordinated care for far too many of our patients, and we have growing levels of care expenses that make many businesses in the care business extremely rich and financially successful.
That brings me back to why I am receiving this award.
Why did we actually do better systems at Kaiser Permanente than the rest of the world has?
Cash flow matters.
Kaiser Permanente is paid by the month for every patient, and they tend to have better care teams, better diagnosis, better treatment plans, better patient connectivity and better care data, because being paid by the month rewards and funds all of those approaches and tools.
The exact Kaiser model isn’t needed everywhere. But buying care by the patient and not by the piece is needed everywhere.
What is needed for our country is to have our major payers buy all care from well-organized plans and buy it by the month and not by the piece — and to have clear and continuously improving expectations about care outcomes, team care, data availability for care, and linkages to care.
The systems people at HIMSS know exactly what would happen if we started looking at the total processes of care, and not just the pieces of care in our system designs.
The golden age for care systems would be accelerated and reinforced and enabled and funded if we changed our payment model for care, and very high numbers of caregivers would love it because they really do not like delivering less than optimal care. They would prefer to be rewarded for saving lives rather than rewarded for failures in care.
We also need to teach everyone the realities of our epigenetic programming for key areas of development for each child born in our country.
Epigenetics — not genetics — determine a huge portion of the wealth gaps and the painful income gaps and even some of the incarceration gaps we see in our country today.
The first two years of life have huge epigenetic impact on each and every child and the people who run the education system for our country tend to be completely oblivious of that reality. It isn’t even on their radar screens—and they will not fix our schools until they put that science right in the center of the screen in each community and setting.
The children who get brain stimulation from simple direct contact with adults in those first two years have billions and trillions of neuron connections happening in their brains that strengthen the brain of each child and that last for life.
The children who do not get those interactions in that first two-year time frame actually do not have a similar opportunity to catch up with neuron connections later in life because the epigenetic reality is that the brain for each child from each group actually changes at age 4.
After age 4, life changes for every child. People don’t know that, but it is true. Systems people who do process thinking need to look hard at that information and understand what it means for all of us.
The brains physically purge themselves of neuron connections at age 4.
There is no functional way to catch up for each child who is behind at age 15 — because the epigenetic process needed to make the neuron connections for each child ended much earlier. We need to help every child from every group at 15 months and we cannot wait until 15 years have passed and have our high schools do that heavy lifting, because that opportunity is gone by that time.
Learning readiness at age 4 is needed for our schools in America to succeed.
Nothing else actually can succeed for those massive areas of failure.
We need success for our children.
We have major learning gaps in our schools. In many schools, fewer than 60 percent of the students can read. In a number of major school systems, only 15 to 20 percent of the children can do basic math.
We currently have massive wealth gaps and we have massive earning gaps in America that have deep roots in a wide range of inter group realities.
We know that the average African American family and the average Hispanic family has a net worth, after Covid, of roughly $20,000 per family — and we know that the average Euro-American family now has a net worth of $200,000.
That is hugely inequitable and it is painful — but we now know that our epigenetic realities are extremely relevant to that process because we know from sheer practicality that we will not close those earning gaps or close those massive wealth gaps when a majority of the people at the low end of the gap cannot read.
Closing those wealth gaps for people who cannot read is wishful and hopeful thinking that verges on pure magical thinking
We know that reading to children in the first two years of life has a huge impact and that neurons connect by the billion when that happens.
We know that 60 percent of the Hispanic children in a California study who had books in their homes in those first years were learning ready at kindergarten — and the Hispanic children in the homes with books learned to read in high school, compared to less than 40 percent of those children being learning ready in the homes with no books.
We also know that a majority of the children in our Medicaid families in America do not have a single book.
The majority of births in America this year will be in Medicaid homes. That actually gives us a major opportunity. We can easily afford to put the right books into all of those homes and we can have Medicaid support that process.
If we really believe that Black Lives Matter — then we need to build on the epigenetic realities that exist for every child, and we need to get adequate numbers of books into those homes.
The WIC program for low-income children in Los Angeles got books into Medicaid homes and they had up to 70 percent of those children learning ready at age 4.
We need to help kids everywhere.
We need optimal systems everywhere as well.
We are on the cusp of a golden age for health care systems. We will not take full advantage of that golden age if we continue to buy care badly and if we continue to have far too many children on the wrong trajectories for their lives.
So, thank you for this award.
Let’s use this opportunity to build the right systems for both payment models for care and support models for our children going forward from here, because it clearly is the right thing to do — and doing the right thing is clearly the right thing to do.