Accountable Care, health innovation challenges, HealthIT, population health

On the ‘N of 1’ As a Standard for ‘Accountable Care’

by Gregg A. Masters, MPH

When I penned the post, ‘CTE on the Accountable Care Agenda? Junior Seau it’s latest victim?‘ in 2012 my intention was to draw a circle around seemingly unrelated events now finding increasing conversational gravity in the emerging ‘population health‘ zeitgeist where social determinants of health are valued as strategic grist for the mill of health systems and especially their ‘integrated‘ bretheren’s leadership.

It was also my hope that the commentary might generate some sober conversation in the healthcare social media, healthtech and healthIT social media communities. Much to my dismay, there was none.

The causes of this silo-ed, episodic, ‘we’re not concerned with life or health related events that occur beyond the walls of our cathedrals of medicine‘ sick care focus are well known and documented. Though mitigated somewhat by select provisions in the Affordable Care Act with emphasis on transitions of care, avoidance of 30 day re-admissions and continuum of care coordination particularly in the long term, post acute care (LTPAC) space, it’s mostly ‘modified” business as usual in U.S. Healthcare operations.

Oft referred to as the ‘burning [fee for services] platform‘ now clearly in the crosshairs of regulators, health industry leadership, payors, employers and even patients as the source of the problem, everyone is now focused on ‘value based healthcare‘ as the ecosystem’s likely successor footprint.

Yet, we do have a long way to go.

Case in Point

As someone who’s been in the belly of the beast of the ‘healthcare borg’ dating back to the mid 70s, I have witnessed and been to more or less degrees both a strategist (‘disruptor’) and implementation principal to successor waves of ‘innovation’ – ALL intended to tame the rapacious appetite of our ‘do more to earn more‘ healthcare financing and delivery ecosystem.

Decades later the bottomline is we’ve failed, writ large and collectively as an industry. The healthcare spend run rate as a percentage of GDP (then 8%) is now approaching 18-20%., where one out of every five dollars spent in the U.S. finds its way into the coffers of the silo-ed sick-care system we’ve collectively co-created. And while the change or re-engineering imperative was then limited and contained behind mostly closed door board rooms of health systems, health plans and large self funded employers or multiple employer trusts, today that ‘conversation’ is top of mind for our nation. Then, only corporation’s and government’s financial stability were ‘at risk’, today it’s entire nation states at peril.

So clearly something must be done. It must be bold (all inclusive), truly innovative and impactful. No mere tweaks at the margin will do and this may be the last hurrah for a public/private partnership to succeed before the Government has to intervene and solve the problem from the ‘top down’.

Enter the Triple Aim, Value Based Healthcare and the Population Health Mandate

There is non-stop discussion at meetings, conferences, webinars and expositions on the subject of a structural and scaleable pivot of ‘U.S. Healthcare Inc.’, from it’s Fee For Services (FFS) roots and incentives to a successor, sustainable version. Perhaps best framed by Don Berwick and the Institute Healthcare Improvement (IHI) as the ‘triple aim’, the charge to healthcare industry leadership is for a better experience of care, with better outcomes at lower per capita costs.

This ambitious tasking rightly shifts the focus of health system leadership from that which is customarily provided within the walls of the acute – and now subacute – delivery system operating units, to the ‘upstream‘ arguably ‘roots’ of the social determinants of health as discerned by proactive risk stratification coupled with outreach to defined populations.

Technology As Enabler?

Concurrent with the pre-occupation on value based healthcare and emerging focus on population health management, we’ve been discussing and evidencing the value of ‘mhealth’ or ‘digital health‘ apps, platforms and technologies to nest inside current clinical workflows (and beyond?) and fuel delivery of the triple aim. Yet, closing in on a decade later (the iPhone launched in 2007) there is sparse and limited evidence of the salutary benefit of digital health apps to make a dent in the aggregate quality, cost and access challenges we face as an industry.

Whether we’re in collective denial, have all drunk the ‘kool-aid’ thinking this time will be different or simply point to some evidence based believe or faith that technology can serve the greater good of the triple aim’s goals, the expectations and stakes are high – very high in fact. Much talk about contributions from AI, Big Data, Gamification, VR, the Internet of Things and even the Internet of Medical Things, all get woven into often lofty forward looking tech-speak and even policy solutions of how we’re going to make this happen. Yet is this warranted?

A Long Way to Go

A recent experience of mine suggests much work remains ahead. As indicated in the Junior Seau (RIP) post there is a grand canyon divide between the ad copy and rhetoric of population health initiatives and current healthcare operations and financing.

In November I moved to South Lake Tahoe for the ski season. I am 65, in general good health and reasonably active (I surf in San Diego) and recently qualified for Medicare and chose to enroll (i.e., assign my benefits) to a private sector alternative operating under Part C as the ‘Medicare Advantage’ (NOTE: which is a misnomer, since it isn’t Medicare but rather a private and in some markets ‘enhanced version’ when when the health plan is profitable) program organized by Kaiser Permanente in San Diego California. Kaiser Permanente (KP) is a trophy IDS (integrated delivery system) and is often and rightfully acknowledged as ‘best in class‘ in their approach to the organization, delivery and financing of healthcare services. I agree, and thus elected to enroll via their ‘Senior Health Plan‘.

KP has made enormous investments in HealthIT having adapted EPIC to serve their regions’ individual operating units. KP has also embraced technology and innovation via their Garfield Innovation Center and present with a well staffed and focused social media enterprise that seems linked to its member services group.

The Event

On Friday, I headed up to the summit at Heavenly Mountain with my girlfriend Lori. Upon exiting the Gondola and traversing up to the Ski lift to the Summit I started to feel light headed, stopped, looked up and collapsed backwards. According to Lori:

‘your eyes rolled up, your face went pale and you looked expressionless. I was alarmed.’

None-the-less, determined to get to the top for the first run of the season I elected to proceed and we entered the lift to the Summit. On the way up, we had cross winds gusting between 20-30 MPH. The temperature hovered in the low 20s to teens and the air was thin and dry.

I was wearing a ski dickey and found it difficult to speak and breath. Clearly this was not normal. Yet, we exited (9500 foot elevation) and began our decent down to Tamarack Lodge. Midway through the run I stopped, began to feel light headed and very dizzy. Gasping for air, I leaned onto my poles and then everything went dark. I collapsed again.

Lori took charge, summoned the ski patrol via a passing skier. Ski Patrol arrived, placed me on oxygen, suggested I was experiencing altitude sickness and STRONGLY recommended immediate descent to the Heavenly Center for hydration and rest (65oo foot elevation).

The Social Stream – More than What I Had for Lunch

Once the fog lifted and I began to feel better, I decided to tweet my experience in the public square and tag my health plan (KP San Diego, the Heavenly Ski Center and my Twitter ‘friends’) to alert them about my experience. For both my twitter colleagues and the Heavenly Center it was an FYI with a Ski Patrol shout out to Nathan (the EMT).

For KP San Diego it was a ‘heads-up’ as in hey, this happened to me today and ‘I think you should know.’ Now I know KP has a patient portal via MyChart and one I’ve been in and out of a few times, in addition to a ‘go to the emergency department‘ when in need advisory. Yet, we’re in the age of population health, risk assessment, prevention and ‘patient generated health data’ (PGHD) including massive investments in ‘listening’ technology for the rich streams of content posted to social networks.

Now add the fact that healthcare is a litigious and thus risk averse environment. Therefore sitting on the sidelines and at best ‘listening’ is probably less risky than realtime or ‘asynchronous’ attempts to ‘intervene’. I’m sure a bevy of corporate lawyers counsel against ill advised engagement outside the normal ‘theater of operations’. Yet, I am old enough to remember when the Darling and Nork cases began to peck away at the immunity from liability traditionally argued by many hospital administrators that ‘we’re just the doctor’s workshop’ and have no control (and by extension no liability) for their actions. Yup, that once was the standard of practice a few decades ago.

The Messaging

Here are the series of tweets posted related to this narrative.





The Health Plan’s Response

Several days later… and in ‘async’ fashion KP weighed in via Direct Message on Twitter. I previously tweeted about my inability to reschedule a colonoscopy from a San Diego location to the Sacramento area since I am in South Lake Tahoe for the ski season. I learned that I could NOT opt for a local option as the health plan didn’t operate that way [paraphrased]. The tweets below pertain specifically to the incident on the mountain.

Hi, Gregg. I noticed your recent tweets and wanted to follow back up with you. If you’ve already sent your email, we have not received it. Can you please resend it? Thank you! ^Jamison

Gregg Masters MPH @2healthguru

No point in sending log to you. After DM, spoke to my PCP. She advised I can not schedule colonoscopy in NorCal (Sacramento) w/o changing PCPs. Suggested we delay until I return to Oceanside in April. Really bad form for KP. If true, you are NOT an IDN, but a federation of providers under a common marketing banner with discrete regional accounting, but worse clinical operations. I am VERY disappointed, since I am and have been a fan of KP. I am 65. I’ve been self employed since 2000, and un-insured by choice since. My health plan is my health. If KP is committed to my health, then a simple risk profile of these facts would expedite the colonoscopy as a preventive tool. I shouldn’t have to point this out to my health plan. Then add my fainting on mountain at Heavenly (9500 foot elevation) with minimally hypoxia if not cerebral edema, AND ZERO recognition or comment from @KPsandiego who I tagged [in tweet]. I mean seriously, with the investment made in tech, how can you not leverage proactively on behalf of your members? I am shocked. If this is M-F brand listening tool only and not deployed as adjunctive to KPs clinical risk management surveillance program, you are clearly missing the boat of the PGHD wave that is sweeping the ecosystem under the banner of ‘digital health’ tools. Again, I am a KP fan and believe you need be held to a higher standard given all the accolades received via others in the industry. Please pass this concern in its entirety to both Robert Pearl and Bernard Tyson who I personally hold responsible for these systemic (x2) ‘fails’. I am blogging about this experience (including this response) as a N of 1 example of ‘accountable care’ in the new age of population health contextualized via social [i.e, lifestyles of] determinants of health plan members (including their known risk profiles). Thanks for asking. My concerns go considerably beyond the usual scope of member services, and I do hope you pass on my comments in their entirety to senior leadership. My blog comments will be posted to @ACOwatch as my N of 1 version of ‘accountable care’ to this post:… Thanks Gregg

Thank you for your detailed reply, Gregg. I will definitely make sure to pass along your experience and concerns to our senior management staff. ^Jamison

Much To Do About Nothing or Reflexive Provider vs. Patient Centric Response?

One can argue,  hey dude work within the system, i.e., call/alert KP via member services, enter a note to your PCP in the MyChart portal or head to an Urgent/Emergent Care Center – quit whining.

Yet, am I wrong to think that in an era of ubiquitous, real time and ‘asynchronous’ tech stacks afforded by major social networks where participants are ‘tagged’ as in a ‘headsUP’ fashion, need be viewed solely as a forum for posted images of cats or what’s on the menu today?

When and where do we walk the talk of the upside of digital health tools, the value of patient generated data and the big data and massive analytics engines that routinely data-mine these streams for population health insights and actionable ‘intelligence’?

So maybe this is just too much to expect even from best in class performers – the likes of KP. Maybe the residual ‘resistance ifs futile’ legacy inertia is just too powerful to overcome systemically and we’ll just have to be happy with at best tweaks at the margins.

I for one think we need to up the ante and hold both the providers and financiers accountable to this dysfunctional ecosystem we’re so often powerless to influence or change.

I am committed to make a difference. Where are  you?




Accountable Care, ACO, Affordable Care Act, HealthIT

Catching Up with Farzad Mostashari, MD: An Aledade Preview at HiMSS 2014?

By Gregg A. Masters, MPH

The HealthInnovation Media footprint was again on the ground at Health Information Management Systems Society (HIMSS) 2014 in Orlando, Florida. One of the privileges I enjoy as producer and creator of all digital content generated is I get to tag interesting people to put in front of the camera including suitable hosts for each interview segment.

In this shoot we meet with former Director of the Office of the National Coordinator for HealthIT and now Founder and CEO of ACO management company Aledade, Farzad Mostashari, MD.

The interview was masterfully handled by industry veteran and colleague Neil Versel.


Accountable Care, ACO, HealthIT

An ACO ‘Deck-o-Topia’ at HiMSS14

By Gregg A. Masters, MPH

This is the fourth year in  row that I have participated in the largest annual gathering of parties in interest to the health informatics ecosystem. From payor to provider to regulator to vendor to the patient and/or consumer of healthcare services, there is always much flare to consider, discard or assimilate. HIMSS14

This year’s gathering is expected to attract somewhere between 30 to 35 thousand attendees. Second only to CES the HiMSS sea of humanity is a distinct strain of conversation to experience.

From one of the tracks that directly appeals to readers of this blog is the track devoted to accountable care and/or ACOs in particular. More later with an individual dive into the more interesting presentations, but the entire decks can be accessed via: Transitioning to Fee-for-Value through ACOs, Care Coordination and Clinical Integration.

Accountable Care, ACO, digital health, HealthIT

Accountable Care, mhealth and the Triple Aim

By Gregg A. Masters, MPH

For those of you following this blog you know I write about ACOs and the emerging accountable care zeitgeist. My lens has been forged by decades of experience in the ‘managed competition’ experiment. For an earlier piece see: Some Context and Perspective on Standing Up the ACO.’ HCFA masthead

The managed competition industry – perhaps more widely known as ‘managed [though more accurately mangled] care’ – can be traced back to it’s regulatory oversight origins via an office in the predecessor agency to CMS, the Health Care Financing Administration (HCFA) titled the ‘Office of Alternative Delivery Systems’ (OADS).

The mission of the OADS was to monitor the then emerging (‘disruptive’) players in the HMO domain but also this little known but ‘HMO lite’ mutation dubbed ‘preferred provider organizations’ (PPOs). The alternative delivery system domain was typically populated by those operators who compensated their contracted network of physicians, hospitals and ancillary providers via other than routine fee for services based payment. Alternative compensation ranged from mere discounts of standard fee schedules to full or partial capitation for physician or even hospital services, thus ADS operators could be arrayed across a continuum of risk assumption.

It is interesting to note that what was then considered ‘alternative’ to prevailing or normalized healthcare financing and delivery is now the new ‘normal’. Yet, we hear more reference to ‘alternative delivery systems’ today as representative by such new age/zeigeist disruptors the likes of certain ACOs, medical homes or even the tapestry of direct, membership, retainer or even ‘concierge’ models of delivery – including hybrids (OneMedical).

So in a way, the first phase of the ‘integration 1.0’ cycle is complete and we’re now embarking on ‘integration 2.0’ using the same terms albeit applied to different vehicles. Instead of HMOs or PPOs, we’re talking about ACOs, medical homes or other care delivery innovations.

Clearly technology – both enterprise and consumer facing – are central to the complex deliverable of the sustainable healthcare ecosystem, yet the preferred ‘chassis’ onto which to stitch if not graft the organizational, governance and operational best practices remain somewhat elusive.  To many digital or mhealth enabled solutions seems to represent a fair amount of rational promise to emerging ACOs.

At the 5th Annual mhealth Summit in a session titled: ‘Mobile Enabling the ACO‘ we’ll here from:

…on the state of the merger between promising digital health technologies and ACO operational fulfillment of certain ACA performance requirements .

The session description and schedule is pasted below:

mobile enabling of ACO

ACO, Affordable Care Act, digital health, health reform, HealthIT, Triple Aim

Time for a New ‘IPA’? The Independent Patient Association

By Gregg A. Masters, MPH

India Pale AleFor some ‘IPA‘ is about conversation and spirit enabled conviviality often in micro-breweries scanning the daily options for consumption. While for others IPA conjures up images and memories of labored if not painful efforts to steward the phased transformation of the American healthcare [non]system from a production oriented fee-for-services silo culture to one that is patient centric, team based and ‘what’s best for the patient’ value driven.

FPA Medical ManagementWe were first introduced to the ‘I/P/A’ (independent practice association) acronym in the mid 70s when the HMO Act greased the skids to reach out to mainstream medical staff communities vs. remain domiciled in it’s limited albeit more centrally managed ‘staff model’ (employed physicians) iteration.

Mullikin MedipartnersSeveral decades later, the track record of the IPA to assume, embrace, administer, and ultimately thrive under a prepaid, capitated or otherwise value based compensation system has been a dismal failure. The idea the IPA would seed group practice culture while constituting an increasing share of the individual physician’s practice would ultimately result in ‘urge to merge’ integration of individual practices into a ‘medical group without walls’ if not a fully integrated bricks and sticks merger. Clearly some instances of both have materialized, and there are some IPAs today that remain active and vibrant in the resurrected ACO conversation (Monarch Healthcare and Advocate Health Partners are two such examples).

Yet the cold facts are these, healthcare costs remain out of control and out of reach of many (50+ million uninsured, and 75+ [and growing]  million ‘under-insured), while there is no more ‘there, there to health insurance’ (witness the prevalence of cost shifting, benefit reductions and growth of so called ‘consumer directed [high deductible] health plans’, as the fundamental drivers of medical and healthcare cost inflation remain largely immune to industry efforts to reign them in.

Resistance is futileSo might it be the right time to entertain a new IPA? Where the I/P/A stands for ‘independent patient association’?

Between the power of the crowd to leverage ‘most favored nations pricing’ via massive, ‘club based’ group purchasing, and the potential to empower informed patient choices via the emergence of increasingly friendly, smart phone or tablet enabled devices, might we be on final approach to a truly patient engagement inspired revolution as envisioned in Eric Topol’s ‘Creative Destruction of Medicine‘ to select indicia of Patient Engagement reflected in the Affordable Care Act?

So is this a tech enabled ‘power to the people’ moment which taps into, harnesses and drives the granular re-engineering of our house of cards sickcare [non]system from paternalism to patient centricity? Or might this ‘convergence’ qualify as an @Adbusters scenario of:

When the moment is ripe, all it takes is a spark

Can an army of device or otherwise web enabled empowered patients and/or consumers supported by an association that contractually negotiates the lowest possible price points (hospital, physician and ancillary) via large scale, wholesale group purchasing of ‘most favored nations‘ rates be that spark?

Or otherwise put, can this quantum ‘super-positioning’  be the elusive elixir that finally levels the playing field of an otherwise insatiable fee-for-services supply driven demand economy coupled with opaque pricing that disproportionately favors its hierarchical [‘resistance is futile’] inertia?

Might this be the moment for a ‘new IPA?’

ACO, Affordable Care Act, HealthIT, Triple Aim

So What’s with the [ACO] Bundled Payment Thing?

By Gregg A. Masters, MPH

It’s interesting to note the more ‘things change’, the more they ‘[seem] to stay the same?’ Let me explain….

In a recent observation by Rob Lazerow featured in the post ‘How Are ACOs Doing‘ the Advisory Board Senior Consultant dubs 2013 as the ‘year of accountable care’. He then goes on to highlight the ‘bundled payment’ program as the center of gravity in ACO market movement since:

It has nearly twice as many provider organizations compared to those participating in the shared savings program. It represents a big spike in experimentation.

Yet, Rob’s newfound gestalt may seem like a bit of back tracking from his previous sentiment as noted earlier via ‘Bundled Payment: A Gateway to Accountable Care? where I engaged him on the subject and value proposition of bundled payment to the ACO movement and holy grail of the triple aim.

So the ‘stay the same’ angle here is more about the herd movement into or out of popular thinking (perhaps even superficial) around ACO strategic issues vs. the granular basing of what we know works, and their real world impediments to local market implementation.

For instance, quite some time ago I penned the following provocative title: ‘Bundled Payment? Lets Start with the ‘RAPERs!’ Unfortunately, I was dead serious then and remain so today, however this bit of granular insight was a tad more than the market wanted to consider then. It received little if any attention and/or discussion, yet it goes to the fundamentals of our ‘healthcare cost conundrum‘. Might it’s reception be different today? Are we really ready to tackle the issues, or will we be content to just keep talking and meeting, with little to nothing changing? We shall see.

ACO, Affordable Care Act, HealthIT, Triple Aim

Are Institutionally Led ACOs ‘DOA’? I Say Heck Yah!

By Gregg A. Masters, MPH

At the end of the [business model and strategic positioning] day, it’s all about the intangible but mission critical ‘C’ word, i.e., culture, and whether two traditionally oppositional styles (physician v. hospital) can mash-up and ‘meaningfully integrate’ (clinically, legally & workflow wise) where previous attempts during the 80s and 90s failed.Are Hospital Led ACOs DOA?

Truth be told, fast forward a couple of decades and that cultural divide has yet to be reconciled a least on average. Granted there are some exceptions (most notably progressive integrated delivery systems who’ve aligned financial incentives but more importantly ‘vision’), and many of the oppositional dinosaurs (physician ‘free agency’ and solo practice are on an accelerated decline) are retiring or otherwise stepping aside. Yet even with the emerging digital natives sporting MD degrees, the cultural divide between clinicians and administrative types (or latter day suits of all stripes), remains a geopolitical land grab just beyond the reach of the individual ‘P’, “H’ and thus ‘O’. Yet, all healthcare is local right, so clearly there are differences based on locality and market considerations.

What’s different today?

Most will say that the difference between PHO 1.0 (for the casual reader or those with a professional event horizon shorter than a decade plus, PHO = a physician/hospital/organization), and the ACO movement spawned by the Affordable Care Act and most visibly iterated as PHO 2.0 roll-ups (since many of the more visible and publically tagged ACO efforts include an ‘H’) nets out to an accessible if not the ‘new and improved’ ubiquitous technology edge, coupled with smarter ‘productivity’ systems to hold docs accountable post acquisition (risk transfer) of practice assets or hiring.

Back when the internet was just getting going circa the 1990s and Jim Clark was pushing the Healtheon vision – an ambitious agenda to virtualize if not harmonize the complex healthcare ecosystem, we did not have the ubiquitous connectivity and prevalence of user friendly devices including mobile and tablets or the enabling bandwidth let alone national coverage.

Reading the ‘tea Leaves’

Yet even in the face of ‘smarter people’, ‘better systems’ and increasingly accessible, ‘robust cloud based services infrastructure’ (IT and otherwise) with attractive price points, is the people challenge any different today? At least two data-points suggest otherwise evidencing the underlying ‘dis-ease’ associated with the implementation complexity of a ‘soft sell’ re-engineering of American healthcare via the aggregate market uptake of ARRA, HITECH and key ACA (ACO) provisions.

According to a Athena Health’s 2012 ‘Physician Sentiment Index‘:

  • 69% believe EHRs can improve patient care, down from 75% the year before.
  • 75% believe achieving Meaningful Use is a burden.
  • 53% believe the Affordable Care Act will be detrimental to patient care, up from 50% the year before.
  • 58% believe most or all of the Affordable Care Act should be repealed, and 26% believe that some elements should be repealed. Only 16% said to keep it as is.
  • 63% believe the shift to Accountable Care Organizations (ACO) will have a negative impact on profitability, up from 48% last year.
  • 54% believe the quality of care will decrease over the next five years.

Add to the mix the following headline: ‘Physician Turnover Hits New High as Demand for Primary Care Increases’, which reveals:

physician turnover reaches the highest rate since the first year data was collected in 2005, and exceeds pre-recession levels. Medical groups reported an average turnover rate of 6.8 percent in 2012, according to the 8th annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA).

The survey also reported turnover of 11.5 percent among advanced practice clinicians (APCs), which includes physician assistants and nurse practitioners.

Also noteworthy is from the report’s ‘Other Key Findings’:

‘Culture is the Top Controllable Turnover Factor: Lack of cultural fit was the third most common reason given for voluntary departures, and the most common factor within the control of a medical practice.’

‘Demand for Care Teams Intensifies: More than three-quarters (76%) of respondents plan to hire more primary care physicians in the next 12 months, 67 percent plan to hire more nurse practitioners and 61 percent plan to hire more physician assistants. Strong teamwork skills will be vital to successful coordinated care.’

Bottom Line

So that ‘primary care sucking sound’ (remember Ross Perot’s NAFTA warning?) mostly to build out and staff ACOs, medical homes and their derivative ‘high value’ networks, are creating an environment where the natives are clearly restless, while the disconnect between industry rhetoric and the on the ground reality of the transformational imperative has never been more acute, nor the stakes so high.

ACOs were purposefully visioned as physician led enterprises, yet as is often the case in healthcare innovation amidst a change resistent ‘just say no’ culture the capital partner steps in to steward if not direct the initiative’s vision of organization, governance and equity (fairness if not capital) issues. Moreover, hospitals (or their parent systems) are the likely source of ‘capital’ – financial, managerial and infrastructure, ergo they step into the void of physician leadership to move the needle albeit in their narrow view of self interest.

Most institutionally led ACOs therefore are dead on arrival unless there are compensating factors which infuse [group practice] physician culture at the center of the enterprise in pursuit of the triple aim, or hedges where hospital executives clearly see their role as transitional enablers and not drivers of a physician seeded transformational process amidst a sea of conflicting incentives, values and workflows.