Disruptive Innovation v. EHR Optimization: Is the Tail Wagging the Dog?

Disruptive innovation in healthcare will depend on new combinations of data, technology and business models to create new interactions with health and healthcare consumers. In a NEJM Catalyst Marketplace Survey, healthcare executives, clinical leaders, and clinicians ranked the healthcare sectors in most need of disruption. The top three sectors were hospitals and health systems (65%), healthcare IT vendors (47%), and primary care (36%). Interestingly, a dichotomy emerged when respondents considered whether buyers were willing to pay for solutions to result in disruptive innovation. Most notably, health care IT shot to the top of the list, named by half of respondents. Hospitals and health systems were second (46%).

Importance of EHR Optimization

Yet according to a recent Health Data Management survey, 72% of respondents from healthcare organizations indicate that achieving EHR optimization is either extremely important or very important for their organizations. Healthcare leaders vary in their definition of optimization. For some it consists of routine maintenance, for others it involves remediation of technical issues not addressed during implementation, and for others it includes the addition of new functionality. The performance-improvement minded define optimization as including standardization of workflows, improved use of data and application of best practices. There are three problems with this thinking:

  • At best optimization produces incremental performance improvement and change, resulting in a nominal return on investment and value,
  • Second, optimization is focused on the technology not the healthcare business or clinical problem to be solved – resulting in the proverbial technology tail wagging the dog, and finally
  • There is a perception that disruptive innovations must come from outside the industry, and if the data and technology leaders are “heads-down” focused on optimization, they may miss the chance to drive real change

Solving Narrow Business and Clinical Problems is the Key to Disruptive Innovation

Disruptive innovation requires one to solve the business and clinical problems of the industry. These problems are big, complex and often beyond the control of individual practitioners and health systems. For the best lesson on addressing complex problems, we can look within our own industry. Cancer, once a death sentence, was the focus of doctors and researchers for years. The common thinking was that a single cure for all forms of the disease would be the answer. Physician Sid Mukherjee, author of book The Emperor of All Maladies, describes the first breakthrough.  Sidney Farber, now known as the Father of Modern Chemotherapy, decided to focus exclusively on treating leukemia. By narrowing his focus Farber was able to make remarkable progress against this single condition. As a result, his work led to new protocols and treatments for other cancers. According to Mukherjee, “focusing microscopically on a single disease, one could extrapolate into the entire universe of diseases.” The healthcare industry can learn and apply this lesson – to solve solve large complex problems, first attack smaller micro-problems.

Move to the Next Level of Value & Return on Investment

There exists a full spectrum of high-impact value that can be realized and created when investments in HIT and digital tools are applied to solving healthcare business and clinical problems. The Healthcare Value Pathway illustrates the next levels of value and return on investment.

Key steps include:

  • First of all, start with a narrow focus on a specific problem such as the historic under-investment in primary care, the cost of a hospital stay, patients with multiple chronic conditions, the disparities in access or challenges in transitions of care
  • Next explore specific innovations such as:
    • Design new business and care delivery models
    • Develop new networks new networks of patients and providers
    • Create new approaches to sharing information
    • Reinvent work processes, decision making structures and roles/responsibilities
  • Analyze market, clinical, financial, claims, social determinant, etc. data to learn more about the problem to be solved
  • Finally, iterate micro-phases of designing and piloting the innovation

Oh, and what about technology? Technology is and will be pervasive in all that we do in health and healthcare. Consider as you design new innovations, potential high-impact or value-added technologies.  Rather than “wagging the technology tail”, move beyond optimization to focus value through disruptive innovation.

The Pivot: From Compliance to Strategy

HIMSS16 – billed as the largest and most important healthcare IT conference in the United States occurred last week in Las Vegas.  The message was loud and clear – something is different; the government mandate is over.  Strategy is the new, new.

For years the HIT world has encouraged alignment of enterprise strategy and the IT plan.  Alignment suggests two distinctly different things creating a linkage or connection.  Healthcare enterprise strategy decisions such as which markets do we enter, who do we acquire, which service lines do we emphasize, and what capital investments do we make are explored at executive and board levels.  Operations and financial decisions to support our hospitals and physician practices are made within organizational silos.  Sometimes IT is at the table, but more often than not information systems professionals are called in after the fact to “implement” selected systems and tools.  Sophisticated IT organizations have created IT Strategic Plans, IT Governance structures, IT Road Maps, and IT Champions/Customer Relationship Managers.  Our challenge – separate, sometimes aligned but rarely one.

Uncertainty is the new normal.  Strategies that take years to implement, vendor partners who are all vying for the same space and the challenges of mergers and acquisitions are driving us from 1.0 healthcare – where business as usual no longer is sustainable.  We are at a cross roads.  Those of us in transition must “pivot” our viewpoint from 1.0 volume based thinking to 2.0 and beyond.

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We need fresh, new perspectives regarding the relationship between enterprise direction and the digital strategies required for the future.  New harmonized strategies will:

  • Vary by geographic market and depend on community progress toward clinical integration
  • Necessitate partnerships, alliances and consolidations – no one can fund the investment alone and no one vendor will have all the solutions
  • Require governance models that address horizontal, vertical and virtual decisions making and integrate change across multiple systems of care
  • Move from an applications focus which emphasizes feature, functionaliy to a platform focus, producing highly configurable systems which will drive standardization and enable business strategies simultaneously
  • Redesign our organization structures, leadership competencies and operating models in IT, Informatics, Analytics and Quality
  • Acknowledge our work to create systems of documentation was foundational but not the end goal; systems of insight and behavorial change are the next stages in the evolution
  • Result in convergence of people, process, information, change and technology to rationalize costs, manage risks, realize value and activate patients to become involved in their care

 

Beware Best Practices

Almost twenty years ago, in 1996 after publishing “America’s Health in Transition: Protecting and Improving Quality”  the Institute of Medicine launched a long term, ongoing concerted effort on assessing and improving the quality of healthcare.  “To Err is Human” further galvanized the national movement to improve the quality and safety of our healthcare practices by putting the spotlight on how tens of thousands of Americans die each year from medical errors.   The “Quality Chasm” report underscored the importance of a dramatically improved information technology infrastructure to support a 21st century health system.  Building blocks for such a system include an electronic health record system and national standards.  Progress has been made, the federal government has paid out over 30 billion dollars in Meaningful Use incentives as of March 2015 and impressive examples of quality improvements are frequently quoted in the literature.  Yet, most would agree that the results to-date have been underwhelming.

It is important to recognize that most implemented EHRs with a “check-the-box” mentality order to comply with Meaningful Use.   When Meaningful Use was initially launched, our team suggested that we were “enabling the dinosaur”.  And while not prehistoric, the design of today’s healthcare system does have ancient roots.    The Romans constructed buildings called valetudinaria for the care of sick slaves, gladiators, and soldiers around 100 B.C. (Heinz E Müller-Dietz, Historia Hospitalium, 1975).  In the U.S., the number of hospitals reached 4400 in 1910, when they provided 420,000 beds (U.S. Bureau of the Census, Historical Statistics of the United States 1976).  So clinical information technology was about automating existing clinical processes in hospitals (Stead 2005) rather than transforming clinical decision-making and work processes across the care continuum” (Brown, Patrick, Pasupathy 2013). 

 Separately, quality and performance improvement departments focused on deploying best practice – a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. (Wikipedia).  While best practices have their place, it is important to recognize the risks associated with emulating others when the practice depends on an antiquated business model such as hospital care. JPGshutterstock_159756653

As health systems transition from 1.0 – Bricks and Mortar Healthcare to 3.0 – Digital, Value Driven Connected Health and Healthcare, we encourage a focus on emerging practice.  A concept born in “systems thinking”, emerging practice assumes:

  • We cannot copy other organizations, use it in our organization and expect it to work given the number of variables at play
  • Intentional design of care management and business models will result in disruption of today’s best practices
  • Collaboration and integration of clinical teams, business leaders, information technology experts and data analyst will create new value
  • Big bang, long term projects are giving way to agile, experimentation where we learn to work in new and different ways
  • Rather than using our intuition or past experience to drive improvement, data driven innovation can often have more remarkable results and new practice will emerge

So, the next time someone mentions “best practice” challenge their thinking.

 

ROI and Vendor Sales Strategies

Maestro Strategies has worked with numerous vendors over the years to measure and document return on investment (ROI) to support vendor and service company sales efforts. Our approach has focused on providing an objective, independent and analytical perspective on the value of the solution from the view of the healthcare customer – health system, clinician, financial executive, etc. Typically, we validate hypotheses developed in conjunction with the company, in a number of real-world customer settings and create a model that can be used to project quantitative and qualitative benefits for prospective customers. Much of our work has been focused on expanding the conversation to examine both financial return on investment as well as strategic and process value – tangible and intangible. As one would imagine, over the years we have seen products implemented that were not used by their customers, solutions implemented on top of broken processes, systems whose users resisted mandated components of the applications, and complex modules whose capabilities were only partially configured and deployed – along with products and services that drove significant value for their customers. However, in all cases, potential benefits of the solutions and ROI were not fully realized. The reasons were many – health systems implemented without redesigning processes, executive sponsors didn’t remove barriers, projects weren’t managed well, and oh yes, sometimes the products didn’t deliver promised results.

The transition from volume to value by the healthcare industry will change the rules for both solution companies and their customers. Features, functionality and demonstrations will no longer be enough to drive sales, industry consolidation will reduce the number of customers, and ultimately solutions companies that don’t produce value over the entire life cycle of their product or service (e.g. beyond sales to include implementation and support) will be replaced by those who drive value creation, realization and results. Many solutions companies are developing ROI and value realization measurement tools and methodologies. Maestro’s experience in working tells us that often solution companies and their healthcare provider clients have different goals for the relationship, different perspectives on the value question and different language in explaining benefits.

Presentation1 Different Definitions of Value

 A Joint Value Management Plan that maps out agreed upon initiatives, value targets, milestones and accountabilities is essential to drive successful adoption, use and value creation/realization. Sometimes separate initiatives are occurring in parallel with the implementation and attribution becomes challenging.  Maestro works with both the solutions provider and their client to define common definitions of value and ROI, validate actual realization, understand key levers and accountabilities that will ensure ongoing value.