Physician Strives to Create Lean, Clean Health Care Machine.

Studies of manufacturing processes may one day help make your practice more efficient

Elisabeth Hager, MD, MMM, CPE, is teaming up with scientists and industrialists to teach physicians how to apply principles of lean, total-quality manufacturing to their practices. She believes innovation and efficiencies can help doctors resurrect their profession's image and their control aver it--and perhaps even reinvent American health care.

THE TYPICAL AMERICAN medical practice is sitting on a gold mine. And Elisabeth Hager, MD, MMM, CPE, believes doctors can save themselves, their patients and even the medical profession if they'd only learn to mine the gold.

The treasures are the data in patient records. Hager says the data render valuable information for a practice that could fuel other branches of the health care infrastructure. Here's one scenario:

* The data can tell a practice how much it costs Physician X to treat a patient with diabetes and compare it to Physician Y's costs.

* It can help the practice determine what percentage of patients have diabetes. If it were, say, 43 percent, perhaps the doctors could hire a nurse practitioner to stage monthly lunches for diabetic patients on nutrition or foot care.

* The patient education could reduce individual patient visits.

* Better-educated patients become satisfied and have better outcomes.

* The practice gets a reputation for its innovation and gains leverage with insurance companies.

"They could incorporate that into a business plan," Hager says. "They could go to an insurance company and say, 'I want to have my nurse paid X amount of dollars to do diabetes education, and here's the schedule."'

Doctors, like anyone, ought to reap financial rewards for excellence, she says. But Hager's find-a-better-way dogma isn't about efficiency and cost saving for their own sake. Her goal is nothing less than transforming health care in this country and saving the medical profession as we know it.

Hager, a psychiatrist--and one-time would-be clergywoman--with degrees in sociology and medical management, downsized her Rochester, N.Y., practice and left direct administrative posts to devote herself to preaching the gospel of entrepreneurship, innovation and total quality management for health care.

Hager teamed up with industrialists and scientists in a National Science Foundation-funded project--New York's Upstate Alliance for Innovation--to develop a business hatchery. The goal is to create science and technology-based businesses out of innovation, perhaps to launch the next Silicon Valley.

And she works with manufacturing theorists and practitioners studying highly efficient organizations to apply the concepts of lean enterprise to health care.

Hager is based at the Rochester Institute of Technology's Center for Integrated Manufacturing Studies--an unlikely place for a physician. Her task at RIT is developing self-education modules in lean-enterprise principles for health care professionals.

For other entrepreneurs outside health care, the holy-grail efficiencies they seek will result in greater profit. Doctors aren't immune to the same lure, she admits, but for Hager, there is a higher calling.

By leveraging their expertise, information and skill, and by questioning prevailing habits and assumptions, doctors can take charge of health care again, Hager believes. Savings and efficiencies can free up the money, time and, most importantly, brain power for patient care--the very thing medical consumers want, the very thing that only doctors can do, the very thing that will restore physicians to the top of the trusted professions.

"Doctors can do it all," Hager says. "Our profession, the profession of medicine, depends on it."

Great ambitions

Hager, a Chicago native, studied chemistry as an undergraduate but didn't go directly to medicine. Instead, she pursued a graduate degree in the sociology of medicine at the University of Missouri in Columbia. She was teaching interviewing skills to medical students when it dawned on her: They're no smarter than me.

And she figured if she had a PhD and an MD she'd be more likely to get grants. She earned a master's but didn't get that doctorate, however.

Looking back, Hager says she had ambitions to affect the world and saw three career options:

* Education

* Religion

* Medicine

She leaned toward teaching, but concluded that health is the foundation for other helping professions. "I decided if I could make others healthy they could go Out and be priests or nuns or ministers or they could go out and be teachers."

She was accepted to medical school and scored a zero percent loan for her education --which now strikes her as an example of medicine's occasional disconnect from the rest of the world. "I think that was ridiculous. Nowhere else in the world could you get a zero percent loan."

From the sociology department, she went to Missouri's School of Medicine, taking a year's leave of absence to raise a newborn son, now 18. Then, it was back east with her New York City-native husband to an internship at Rochester General and a psychiatric residency at the University of Rochester and a fellowship in neuropsychiatry and geriatric psychiatry.

She stayed in the Lake Ontario city ever since, and it's a good fit, Hager says. Rochester's roster of major homegrown, old-economy but technology--based companies--including Xerox, Bausch and Lomb and Kodak--has helped it retain an open-minded managerial class.

And Hager says the metro area of about 1 million is the right size to open up leadership opportunities and build personal relationships. The current head of the Monroe County Medical Society, Hager plans a serious of symposiums this fall for doctors on lean-enterprise principles. She also teaches for ACPE.

Creativity and innovation

Hager says she planned to work on reform from within the system as a practicing physician. But she found herself drawn to examining how creativity and innovation happen, particularly the mental processes involved. Health care, she came to believe, needed an entrepreneurial orientation.

Here, her message can be misunderstood.

Extolling entrepreneurship can sound like turning doctors into businessmen. Hager has done that herself, leading what was once Rochester's dominant IPA and leveraging the expertise it built after a tiff with a major insurer into a support and data-collection system for physicians conducting clinical research. It was called Adroit Research Solutions. It's now disbanded.

What Hager's preaching, though, is more an attitude of examining what can be done better.

"The intention is not to make doctors into businessmen, where they go off and they leave their practices to start companies. It's to bring those concepts into clinical practices so that when they walk into their offices in the morning they look around a little differently."

This can mean elementary stepsavers like moving a fax machine to the spot in an office where nurses answer the phone. It could entail tools like patient smart cards, electronic or paper, carrying basic information such as allergies, primary physician and insurance coverage.

But more broadly, it's realizing that medicine embodies a contract between provider and patient. It's not about adopting a paternalistic relationship, but one that acknowledges the patient's dignity and expectations, Hager says.

Hager describes her program as focusing on increasing end-user patient value in a system that must be concerned about cost to deliver the care. It involves eliminating waste in a system that has remained essentially unexamined over the past century, and by making the processes operate within specially developed quantitative specifications.

These specifications come out of the Six Sigma system extolled by the management theory company of the same name. Six Sigma has worked with some leading companies, including General Electric and Toyota, and uses eight fundamental stages:

1. Recognize

2. Define

3. Measure

4. Analyze

5. Improve

6. Control

7. Standardize

8. Integrate

Hager sees neither lean principles nor Six Sigma analysis as a panacea because human interactions make health care more complex than most industries. Yet, health care can learn from the approaches, she says.

"We need to look at our health care system and each of its processes through the eyes of the customer and focus on the elimination of waste--that is, anything that does not add value in the eyes of the customer--as well as the reduction of error."

If this sounds like the quality assurance promises of HMOs and preferred provider insurance plans, it's important to note that Hager stresses that the change is up to doctors themselves.

She cites a survey showing the profession's trustworthiness rating slipped with the public--now falling behind the ratings of nurses and pharmacists. Doctors are at the center of health care, she says, and need to be at the center of reforming it.

Asking questions

In consulting with a company, Hager discovered that software engineers, not doctors, designed the firm's electronic prescription tools. The tools embodied a great potential for efficiency and error-prevention. Her task was to tweak the software to make sense with a typical practice work flow--something only a doctor can do.

Doctors need to take advantage of information, Hager says. If physicians aren't attuned to turning their practices databases into value, as in the diabetes scenario, you'd better believe insurance companies are.

For example, when Hager was chair of the psychiatry department and medical director of chemical dependency at Park Ridge Hospital, she wanted to learn why patients were ignoring advice and leaving before treatment ran its course.

She had a clerk pull patients' paper records and fill out grids Hager designed with fields for a slew of variables, such as what time of day patients were admitted, who they saw upon arrival, their attending physician and diagnoses. The data were plugged into analysis software and a correlation emerged among patients behaving counter to advice and staff vacations.

It turned out that when staff members were covering for each other during vacation times, new patients didn't meet their primary staff person quickly and positive outcomes dropped. Vacation scheduling was tweaked and the situation improved. It also pointed out the importance of the way the patient was introduced to the staff.

And when Hager had staff doctors track when they changed each patient's medication regime, they made fewer changes. Psychiatric drugs that may need several weeks to take hold then had time to take effect, she says.

Trouble is, medical training and physician society not only don't encourage questioning how things are done, they actually reward accepting the status quo, Hager says.

Who survives residencies? It's the doctors-to-be who are willing and able to sit back and take inhumanely long hours to learn a procedure. It's not the doctor-to-be who asks whether there could be a better way.

"My hope is to show physicians that it's OK to question the way things are done and make suggestions to learn from mistakes."

David Hill, of Ithaca, N.Y., is a veteran newspaper editor and reporter working at Momentum Media.

Elisabeth Hager, MD, MMM, CPE

Current Positions:

Health care consultant: medical entrepreneurship, business development and funding, product development, medical informatics; studying the application of lean-enterprise principles and practices to health care at the Center for Excellence in Lean Enterprise at the Rochester Institute of Technology Center for Integrated Manufacturing Studies; practicing psychiatrist, Rochester, N.Y.

Previous positions:

Founder, president and CEO of Adroit Research Solutions, Rochester, N.Y.; director of clinical strategies, Rochester Healthcare Information Group; board chairman and acting CEO, Rochester Community Individual Practice Association; president, Doctors' Health Plan, subsidiary self-insurance product of RCIPA; president, Community Health and Education Foundation, RCIPA; director of Hospital Services, Unity Health System; chairman, Department of Psychiatry, Park Ridge Hospital, and medical director, Park Ridge Behavioral Health; chief, Division of Psychiatry, Park Medical Group; associate medical director, Park Ridge Chemical Dependency; psychiatrist, Rochester Psychiatric Center, geriatric psychiatry; psychiatrist, Rochester Rehabilitation Center, out-reach program.

Education:

B.A. in chemistry, Hope College, Holland, Mich.; PA Physician Assistant Program, Stephens College, Columbia, Mo.; MA, University of Missouri, Department of Sociology; MD, University of Missouri-Columbia School of Medicine; MMM, Tulane University, School of Public Health and Tropical Medicine, New Orleans, La.

Family:

Married, two children

Quote:

"I decided, from my own experience, that physicians have to be the drivers of health care change. It can't come from industry. It can't come from employers. It can't even come from patients. All of those are very important partners but they can't be the drivers. It has to be physicians because we are the experts."

Relationships, Self-Awareness Key To Hager's Future

As Elisabeth Hager explores the rational world of efficiencies, entrepreneurship and process improvements, on a more personal level she's navigating the slippery world of relationships and societal expectations.

She learned the hard way, she says, that experience, knowledge and willingness to work hard aren't always enough. At a certain level, effecting change requires an understanding of others' needs and agendas.

There are times to fight social conventions and times to work with them, or at least be aware of them, she says. She observes that it was better to be a smart young woman than to be a smart middle-aged woman. It's not ageism, she adds, but rather prevailing expectations, fair or unfair.

"When you're young, ideas are just that. They're cute, they're interesting, stimulating, whatever," she says. She was once told she's a bulldog--which she saw as a strength describing how she got things done. But she's come to realize that such a personality trait also strikes people as if she's a troublemaker.

"It's where I am. It's not cute any more. People don't like ideas because they're threatening."

This self-awareness may serve her well in her push to improve health care. Don't be surprised to find Hager making public policy on health care sometime in the future. Preferably at the federal level, perhaps in an advisory role, she says.

"I don't think I need to be surgeon general," she says, not that she'd turn down the offer.

David Hill