DeSalvo and Tavenner Keynote HIMSS 2014 – an online attendee’s perspective

Here are some observations from this morning’s HIMSS 2014 keynote session with Karen De Salvo and Marilyn Tavenner

Karen DeSalvo from the ONC – clearly she is an accomplished and energetic  speaker.  She gave a great ‘rally the troops’ speech about HIT which must have resonated in the hearts of the HIT and HIMSS crowd.  She clearly believes in HIT and its promise, and mentioned interoperability as a chief goal of the ONC. “Patients should not be walled into data because the vendor doesn’t want to share.“  She is clearly on board with administration speaking points regarding the current unsustainability of health care costs.  “It will be hard.  It will be fun! It will be rewarding” She emphasized her data-driven orientation: “ we need to start providing data to inform new models of care.”

Marilyn Tavenner from CMS – After a policy speak discussion of current CMS internal goals and metrics as well as their star system, ears picked up regarding the tailored remarks towards the end of her speech:

On ICD-10 implementation: “Let’s face it guys – we delayed it more than once.  It’s time to move on.  There will be no delay again.”
On Meaningful use stage 2 : “We understand, and hardship exemptions will be granted to providers/vendors but we expect all providers to be MU2 compliant by 2015”
On data : “Data is the lifeblood of our healthcare system.”

Questions asked:

To Tavenner:  Q: Regarding the challenges with stage 2 implementation, what are you able to do and what about deadlines?
A:  examples given of a vendor not ready with stage 2 technology being potentially eligible for an exemption; or a physician not able to meet hard percentages eligible for an exemption.

                           Q: her experiences with, “lessons learned”

                           A: system integrator was the missing key for a multiply sourced project and they did not have that soon enough.

                           Q: Non-eligible providers.

                           A: excluded on a statutory basis, so little she could do except sympathize.

To DeSalvo:     Q:HIT can help end hunger?

                            A: HIT can help with social service integration

                            Q: Patient identification via HIE/HISP

                            A: Not as difficult as it seems – smart folks are working on patient matching algorithms and demand for this will drive development.

The final comments on the big ideas for the next 5 years: Less fee for service, more care coordination, payment tied to quality, more data being produced to be shared with the public at a reasonable cost.  Finally, DeSalvo described a virtuous feedback loop where available data informs technology that informs care and creates more data, ultimately leading to disruptive change.  (intriguing!)

That’s it for me from HIMMS 2014.  I hope that you found these posts useful and will consider coming back to read some other of my views!

OODA loops – a definition and thoughts on application to healthcare

John Boyd's OODA loop
John Boyd’s OODA loop



John Boyd was a US military pilot who became a military strategist. His chief contribution to military theory was contained in a large slide presentation and one essay, but his teachings heavily influenced those who train our military commanders and are incorporated into US military strategy and tactics. Boyd characterized the decision-making process as a means of a continuous (iterative) cycle of Observation – Orientation – Decision – and Action. This OODA loop is the mechanism enabling adaption and therefore survival.

The observation process involves data gathering, orientation is analysis and synthesis, decision is determination of course of action, and action is the execution of that decision, with resultant consequence. Boyd felt that any model is incomplete (including our own perception of reality) and must be continuously refined or adapted in the setting of new data. This is in the setting of increasing entropy (disorder, uncertainty) of any system once it perturbs from the initial point, which we perceive incompletely and imprecisely due to our human limitations. There’s actually a not insubstantial amount of philosophic thought in that!

It is easiest to conceive of the OODA loop in the setting of a dogfight between two fighter pilots. Each pilot is feeling out the other, maneuvering in a certain way that will best give them the kill, ensuring their own personal survival. The OODA loop is by definition, reactive. But the victorious pilot will be able to out-think his opponent by leaving his own OODA loop and getting inside his opponent’s OODA loop, and therefore predict what that pilot is likely to do. That ability to be predictive with a reasonable certainty, allows the winning pilot to best his opponent, all other things being similar. (skill, plane, etc..)

OODA loops have been applied successfully in business, sports, and particularly in litigation.

In healthcare, physicians have their own worldview or OODA loop. They observe patients, orient their differential, decide on a diagnosis and treatment, and then act on that treatment and observe their results, trying something else if unsuccessful. More experienced or better clinicians have very well-developed, almost algorithmic, OODA loops. They also are functioning in their environment (the practice, the wards, the OR) where they have very specific, well-developed skills to assess when something is amiss – patient flow, quietness, absence of something as opposed to glaring signs (like alarms, etc…).

You could hardly expect the healthcare administrator to have the same OODA loop. Note the Cultural Traditions in the blue box – very different for both! So when the two interact, so do these loops, and may lead to some unsatisfying conversations if there is no empathy between the administrator and the physician. The physician communicates to the administrator, and the administrator communicates back, but neither is understanding what the other is saying. It probably falls upon the more emotionally intelligent of the two to try to get inside the OODA loop of the other to facilitate a truly constructive conversation. Without practiced understanding, the physician risks being labeled ‘disruptive’ and the administrator risks being thought of as ‘unfair’.

Venkatesh Rao, of the sublime ribbonfarm blog, has an older post on his Tempo book blog about OODA’s backstory. I have ‘borrowed’ his OODA diagram here.

More on OODA loops later – we’re really stuck in them in healthcare – a lot more!!