This month, I asked our Disruptive Women bloggers to provide some thoughts on the following question:

There is no question that the health care system(s) in the US is in need of repair; there is no shortage of the number of well documented, significant problems and challenges. But there is another side to US health care: that is, those elements that are working. What would you caution a new President and Congress to preserve, to encourage, to replicate?

The blog posts below explore this topic:

• A Dynamic and Diverse Pipeline
• Health Care Reform & the the Average “Joe”
• Replicating Innovation, Dissolving Boundaries
• Preserving What Works in Healthcare
• Preserving a Diverse Health Workforce
• A Nation of Innovative Problem Solvers
• Performance Metrics: Counting What Counts

The US health care system includes a vast and diverse array of dedicated organizations, institutions and individuals striving to bring quality health care to our citizens. The system includes the front line and hands on workers like those in clinics, offices, hospitals, hospices, laboratories and nursing homes facing the complexities of delivering care in a complex and dynamic environment. The system includes the researchers and scientists seeking answers to some of the most complicated questions of disease and treatment. The system includes teachers and mentors working in schools, colleges and universities helping train the next generation of professionals entering the health care workforce. Our new President and the Congress should assure that we continue to have a dynamic and diverse pipeline of qualified and trained personnel to continue to work in the health and health care system. Workforce development and ongoing education and training is one of the key aspects to the future sustainability of our system and the health of citizens.

With the election around the corner, everyone is hammering about the economy, healthcare reform and the war. Given the critical time in our election history, I found it amusing that I attended the Stanford Healthcare Policy Conference, “Can Innovation Save Healthcare Reform” last week and found the speakers debating the same problems they were talking about 10 years ago. Don’t get me wrong. I bow to the legends at Stanford, like Alan Garber and Alain Enthoven. Those were the giant minds in graduate school that got me interested in healthcare in the first place. But seriously, someone could have peeled me off the floor, I was so bored.

It was like nothing had changed since I left my dorm room in Escondido Village in 1998. It was the same academics muttering about “access, affordability, and quality.” And it dribbled on…“rising healthcare expenditures, cost containment, rationing resources,” …blah, blah, blah. This is why I loved it when Mark Smith, M.D., CEO and President of the California Healthcare Foundation, took the stage and opened his talk with the slightly irreverent comment. He said, “Here we all are talking about healthcare reform, and not one of you has mentioned the patient yet.” I wanted to stand up and applaud (and in full disclosure Mark serves on the Google Health Advisory Council).

I do not pretend to have the magic bullet for healthcare reform in the U.S but here is what I do know about the average “Joe” on the street and what I have learned working on the Google Health team for the past 2 years.

When it comes to healthcare, we are all in denial!

• No one cares about their health until they or a family member gets sick.
• The average consumer (over 52% surveyed) does not understand their health insurance benefits. (Deloitte Center for Health Solutions, 2008 Survey of Healthcare Consumers).

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Ah, US healthcare. It is rather a shocking question to ask what we might preserve, encourage or replicate. But it is an essential systems-level question, because if there is nothing to name (which might be one’s first reaction), then there is probably no realism in the idealism many of us have for change.

I struggle to name something to preserve. I don’t even like the word – it speaks to me of mothballs and museums. Or perhaps that is what we should intend, let’s put the antiquated systems, the major gaps and disconnects, the huge disparities and inequities in mothballs. Let’s preserve them in a museum, to remind ourselves of what a mess we made of it. And let’s disconnect them from the whole, so they cannot damage it any further.

I heartily encourage innovation in healthcare that takes advantage of strong social trends: the Long Tail, social networking, the generosity of information sharing in programs from large to small. We have examples in the Human Genome Project and Facebook Causes. I encourage the most imaginative and disruptive of the current systems to grow in influence, and for us to provide systems around them so they can flourish. Some of these systems are on the ground, in the new space created by imaginative solutions. They are affinity groups, community-based organizations, and consumer-directed projects.

This leads me to what we should replicate. We should replicate the successes, but not without a critical eye to the future. Looming before us are not only dysfunctional systems, but also vast amounts of information, new technologies, and phenomenally creative minds. The systems, programs, and projects that are working need to be proactively attentive to the future, and need not to fall into the trap of complacency, competition, and territorialism. We need to replicate the disruptive innovation that has been a hallmark of good work in the world since the beginning of time. We must look for leadership that has blown open the doors and transformed systems; and replicate not their work, but their ability to identify places where potential energy is waiting to be transformed into kinetic energy.

I say to the new President and Congress: your task is not to play the hero leader, but instead to discover how to unleash the full potential of the people – from the community leaders, to the heads of companies and agencies – by keeping your eyes on the prize in all cases, and witnessing to the deepest truths. Dissolve boundaries, and we will all be freer to lead.

Leaders have a particular burden, and all too often it is mistaken to be one of power and perfection. It is about authenticity, about community, and about compassion. That, with decisive action, measured against the ultimate goals, will transform health.

There are many aspects of our health care system whose continued success we need to assure as we address the great weaknesses of the American health care system. The community health center program provides excellent care for the uninsured and those who rely on publicly-funded programs like Medicaid and Medicare. In many parts of the country the community health centers are leaders in preventative care and the use of health information technology to improve quality of care. It’s a great approach to establishing a broad safety net and we must focus on enhancing and expanding it.

The private market will continue to have a role as well. Our pharmaceutical and biotech industries are responsible for major advances in finding pharmaceuticals to address both cutting-edge needs and rare diseases. Our medical technology industry has developed less intrusive procedures and technological solutions to enormous medical problems. As we seek to eliminate waste and inappropriate care, and as we address the challenges our health system faces, primarily to cover all Americans, improve the quality of care and control costs, we must do so in ways that don’t slow advances in medicine.

Finally, recent government and private sector initiatives to foster public-private collaboration on such issues as information technology, chronic care management, payment reform, access, accountability and patient safety – while they might benefit from careful review – were begun to explore the value of innovative approaches to solving problems and should be retained as we move forward. A fascinating example of such innovations is comparative effectiveness research, on which there is still debate over the most effective and appropriate governance. Consensus must be reached on how to build on the work of AHRQ and others in this critical area of advancing our knowledge about what works and what doesn’t work, so we can target our spending appropriately.

As a leader from the Hispanic community with supportive parents and counselors and with a stellar academic background, I was fortunate to have the opportunity to participate in the Federal Health Careers Opportunity Program (PHS Title VII) – not only to be a program coordinator for a local CBO (East LA Health Task Force, 1980), but as a pre-med student from Stanford University who had not completed the pre-med curriculum upon graduation, I was appointed to an HCOP post-bac program (Creighton University, 1981) and was accepted into UCLA Medical School in 1982 where I served as a counselor for minority premed students for the State of California HCOP program. I know several Latino physicians and public health professionals who benefited from this program and wouldn’t be where they are if it hadn’t been for this program. HCOP has been the major recruitment program for disadvantaged students to enter medicine and public health careers - until the Federal government decided to decimate it in 2006. Now with the current physician and public health workforce shortage along with the tremendous growth in the diversity of the U.S. population, this program should be brought back to its 2005 funding level. In addition, I believe there should be a regional approach to workforce planning and implementation, so that programs in regions with large Hispanic populations target their efforts to bring Hispanic students into the region’s medical and public health schools. The next President needs to understand the importance of having a diverse health care workforce – the literature has shown that Hispanic and African American physicians and dentists generally care for more minority, Medicaid and uninsured patients - the most vulnerable patients in our society, and those who, without health care, tend to be the sickest with the greatest health care costs to the nation.

In thinking about what to preserve, to encourage, to replicate in the current health care system, I kept coming back to the same thought. With a system so fundamentally in need of repair, how is it that we still have outstanding success stories? In a system in which nearly all incentives are misaligned, and the lack of information necessary to make informed decisions is pervasive, how is it that the system works at all?

The answer is that we are a nation of innovative problem solvers, and we have brought that skill to health care. So even in the face of the seemingly intractable problems created by our health care system, problems are solved every day, and solved well. There are many examples – ones that will show up on this blog no doubt - of employers, which continue to cover over 170 million people in this country, successfully implementing changes in benefit design that both improve care and lower costs; of introduction and adoption of new technologies that improve care and decrease costs; of doctors and health care institutions who move beyond the challenges inherent in the fee-for-service environment to provide excellent and efficient care; of systems developed to provide people with full and complete information on cost and quality.

As a provider of technology we see it everyday. We see it in the AT&T Labs where we are working to develop ZigBee networks - named for the zigzagging path data takes to reach its destination like that of a bee zigzagging from flower to flower – to weave together data from short range, low power wireless devices to make independent living a reality. We see it in innovative applications of surprisingly simple technology such as one being developed by our technology partner, Confidant, which uses a teenager’s cellphone to track and improve treatment for Type 1 diabetes. This application wirelessly sends blood sugar readings these teenagers must take multiple times a day to the doctor’s office via a Bluetooth enabled cell phone with a touch of a button. Text message reminders are sent if a reading is missed and encouraging messages sent if readings are regular.

We also see it in the progress that has been made in both the private and public sectors on introducing a continuous stream of new technology based products and developing the standards for interoperability, security and privacy that are necessary for the full scale adoption of information technology in the health sector. And we see it in the resources technology companies like AT&T, with their expansive expertise in building networks, managing information and harnessing the power of computing, have dedicated to development of the necessary standards and products.

We need to encourage this kind of innovative problem-solving in all aspects of the financing and delivery system. We need to recognize that the ability of any and all stakeholders in the ecosystem to develop and implement new ways of doing things will be central to the success of any effort at reform.

Amidst the frenzy of critiques of the US health care systems (yes, there are several), what is still working are the workers, the health care providers - from community health aides and orderlies to chief nursing officers and medical staff leaders - who continue to slog through the detritus of the systems’ dysfunctions, get up every day and try to figure out how to care for patients, their families, and their communities despite the incessant shifting obstacles to meeting that goal. The vast majority of health care providers made their occupational choices with one thing in common: they thought it would be a way to help people suffering from disease and its consequences. Most keep trying to do this.

Reluctantly, I am going to use a war metaphor to amplify. The national discussion on wars often emphasizes the “troops on the ground” and their perceptions of their situation. I try to imagine all those soldiers being asked to divert themselves from their primary responsibilities to collect “performance metrics” so we can find out where they are failing to do their job or making errors. I picture us posting these shortcomings so we can prove that we are transparent. I try to imagine literally hundreds of external experts creating elaborate documents and initiatives designed to ignore the larger enterprise of war and instead creating bureaucratic monsters eating time, resources and even lives in an effort to tinker with the system. I try to imagine soldiers incessantly being blamed in the media for the obvious human errors that wars create. I try to imagine benchmarking this war against other wars so we can see which war is more wonderful. Enough!

I like to think that my analogy is germane because the two groups share a common goal: keeping Americans safe.

In the next cycle of change, I would hope we might get back to the overriding mission in health care: to take care of people faced with challenging health experiences. Quality care and cost containment are polar forces to be balanced. Using the tools of cost containment to assess quality care is at best naïve. Try measuring compassion or the tears of a child watching her mother die of cancer. “Not everything that can be counted counts and not everything that counts can be counted.” (A. Einstein) A bit more emphasis on the mission might change the dialog.

I would recommend the President, his cabinet members, and all the members of Congress try an anonymous three-day hospitalization. They could go through the admissions process stating they have no health care coverage, for starters. The “boots on the ground” might inform the discourse, unveil the impact of provider shortages, demonstrate the nuanced nature of giving good individualized health care, reveal the cost of cost control measures, and introduce them to some providers who are trying to give quality care despite all the disturbances swirling around them.