You Get What You Ask For

I recently had a chance to meet Dr. Dave Levin, the first CMIO from Cleveland Clinic, at the Texas HIMSS conference, where I spoke about Google Glass in healthcare. During his keynote, he gave a quick overview of his book – mHealth: Global Opportunities and Challenges – that I’m reading now.

The most important thing I took away from his presentation is that people will do exactly what you tell them to do, not what you’d like them to do. More specifically, people will optimize against what they’re measured against. This is a classic business truism, but one worth repeating.

In order to receive Meaningful Use cash for adopting EMRs, providers are jumping through an excruciatingly difficult series of hoops. Among those hoops is the primary theme of MU Stage 2: patient engagement.

But patient engagement is not an end. Patient engagement is a means to an end. Although there are certainly disagreements on what the end should be (depending on one’s political alignment), the federal government is clearly pushing value-based care delivered through PCMH and ACO models.

So why are we measuring arbitrary metrics such as “5% of patients engaging with their providers” through some sort of patient engagement product? By incentivizing arbitrary usage metrics, we will see little healthcare delivery transformation, despite all the intent in the world. Instead of flipping the clinic by utilizing patient engagement tools as part of a broader healthcare delivery strategy, providers are just going to optimize to barely get by getting 5% of their patients to send them a message through their patient portal.

Consider instead these potential alternative metrics, that better reflect the spirit of the MU regulations:

1) Percentage of patient population cared for under a value-based rather than volume-based model.

2) Percentage of simple visits – script refills, ear infections, etc. – conducted remotely via telemedicine instead of in person.

3) Percentage of visits avoided simply by answering questions via asynchronous secure messaging/pictures.

4) Percentage of complex visits handled by an MD (in which the intention is to hand off simpler visits/procedures to non-physician practitioners to lower costs)

There are certainly problems with some of these proposed metrics. They don’t solve all incentive problems; the system can always be gamed. But compared with existing measures, the above metrics do much more to force providers to rethink care delivery models and flip the clinic.

Some people will interpret these metrics as a way for the federal government to institute socialist control over healthcare delivery. These fears, though, are disproportionate. While a slippery slope argument can be made in this case, the US government has only on a few occasions actually nationalized private functions. In most of those cases, the nationalization was short-lived (such as General Motors 2009).

Given the clout of the AMA and other players, the probability of sliding down this slope seems exceedingly low. History has shown that there is too much friction in the status quo in the US healthcare system for the system to change on its own. At any rate, some change is better than none!

So, Uncle Sam, hear this: you get what you measure. So please measure what you actually want.

About the author

Kyle Samani

Kyle Samani

Kyle is CoFounder and CEO of Pristine, a VC backed company based in Austin, TX that builds software for Google Glass for healthcare, life sciences, and industrial environments. Pristine has over 30 healthcare customers. Kyle blogs regularly about business, entrepreneurship, technology, and healthcare at


  • Kyle,

    I’ve wanted MU to take an approach something like this:

    Instead of core and menu, I’d like to see a point system. For example, you get n points each for compliance on the core requirements, but no more than a total of 70.

    Then for what’s in the menu requirements n points each for no more than 40 points. You would need a score of 100 to be certified.

    This would build in flexibility, which is sorely lacking by allowing a practice to define which elements are important to them, etc.

    It also would have the advantage that a practice would have a good idea of remaining options for them.

  • Yep, we’ve discovered once again that government bureaucrats can’t come up with reasonable means of measurement.

    What should have been a fairly simple set of requirements, meaningful use has become an unruly beast that merely measures the ability to work the system (sound like any other Gov programs?).

    I feel one of the reasons “people will do exactly what you tell them to do, not what you’d like them to do” in MU is it has never been believed in. Docs were forced into this and there is still that instinctive push back.

    If there was an overwhelming desire to do this (go electronic) because of all the great efficiencies created, then the HITECH act and MU would have never been required.
    Instead, like a kid forced to clean his room, a doc merely does what is required, not what is intended.

    That feeling is waning, to some degree, only through exhaustion. That “shoulder shrug” of , “well, it’s here to stay, and I gotta get my check.”

  • No comments about MU, just some minor corrections…

    No, GM was not nationalized, merely given to the labor unions at the expense of shareholders. So instead of Gov’t Motors, it’s UAW Motors.

    The goal of Obamacare is single-payer — national health care. The goal will have been achieved when the private insurance market ultimately collapses — part of the plan. Then the feds will rush in to “save the day” and we’ll have pure socialized like in the UK, or here at home with the VA, where wait times are astronomical.

    Btw, the AMA has no significant membership (only 17% of doctors as I recall). Its main purpose is control of the CPT codes, with payment for use of same.

  • Yes, I agree with John Brewer. When the advantages of having patient information in an electronic form is evident to healthcare practitioners and patients, they’ll clamor for it.

    When we talk about measuring the results against MU targets, I am reminded of what happened to public education when teachers were required to “teach to the test.” Many teachers who have been around for several decades say the end of meaningful education occurred when they were required to attain a certain percentage of passing scores. At that point, content didn’t matter, only grades. So teachers had to game the system to win the game. One of my former teachers and now dear friends said it drove him out of the profession because it took the joy out of his job.

    How many doctors are being driven out of the profession because they are being measured against artificial targets?

    Healing and teaching are about establishing relationships and improving the quality of others’ lives. Outcomes are highly individualized. Are we missing the point by letting government drive measures against qualities that may be un-measurable?

  • David,
    “the AMA has no significant membership (only 17% of doctors as I recall).”

    The AMA membership is relatively small compared to all the physicians out there, but membership size and influence aren’t always correlated. The AMA has oversized influence when compared with their membership.

  • You are whistling Dixie in the dark – and most of the commenters are missing the main isssue as well. Ask yourself: where is the incentive — REALLY? $8500 (MU payment) is $708.33 per month. Most providers can see patients extra and make that up.

    The problem is that we are asking providers to voluntarily cut their income by asking them to do things remotely. How many remote/telephone CPT codes are bing PAID by insurers (including the government)?

    Bet not many. We’ve never been paid for phone calls either to the nurse or the provider that prevent ER visits.

  • @Sue Ann
    I agree with your number assessment, what is misses is the point at which cash money become reduced reimbursements.
    Also, many local medical organizations (those that negotiate reimbursements for the docs) force their membership to go electronic or suffer the penalties.
    So, if it were simply a black and white issue as you stated, I’m sure many docs would blow this off (which a lot of docs close to retirement are doing)…but it isn’t.

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