Viva la (Online) Primary Care!

Have been a PCP for 25 years, and am a big fan of Health Affairs.. but think they missed the mark on this recent article: No More Lip Service; It’s Time We Fixed Primary Care

In this article, the authors argue for doubling down on our current Primary care system by "making more primary care docs" and "paying them more". Others arguments from the comment section are "let the NPs" do it. Folks- that is like saying Blockbuster just needed to open some more stores to be a little closer to everyone!

In other words, this argument is missing the forest for the trees...big time! As I've mentioned before, We don't have a shortage of PCPs, we just have a shortage of using them efficiently. Every other industry has figured this out- online banking, shopping, travel, and media. Look at the market cap of Amazon and Netflix vs. any brick and mortar company (hint Amazon hit over $1 Trillion in 2018, making it worth more than 21 other major retailers, combined – from Walmart to Costco)

The world has changed, and people want convenient, cost-effective care via web and mobile, just like every other part of their lives. We need to look at the vast majority of routine care and figure out how to delegate routine workflows like refills and pre-visit planning (see healthfinch) and virtualize routine care like minor urgent issues, stable chronic care and preventive checkups (see MDLIVE). And automation needs to be a big part of all this- from expert rules to run workflows to intelligent interviews to triage out the more difficult cases to be seen in the offices.

Primary care needs to be virtual first- with automated triage to the right level of care, and an online provider to deal with the majority of issues. Fortunately no one will go out of business (except maybe the overly ubiquitous urgent care centers) as healthcare is big enough that both "Blockbuster" stores and Netflix can easily co-exist... with the good news is that the combination will be able to take our current number of providers and ensure great care for all in the time and place they want it.

By 2025, it's estimated that over 50% of all care will be delivered online, and that the number of office visits will go down.. but the ones who go into the office will be the ones who really need it. In other words, we need to "un-democratize" healthcare and embrace the fact that not everyone needs to go into the office - we still treat a 22yo with a sinus infection like a 72yo with CHF... but they don't want or deserve the same 15 minute office visit! Let's break that artificial construct (the quote that comes to mind is what Don Berwick referred to as the "Tyranny of the office visit"). Our future will be automation based triage with majority of care being handled online, and then the "Office visit will be Plan B" as detailed by Dr. Tom Lee in NEJM (Jan, 2018).

Viva la (Online) Primary Care!

What can the healthcare system really learn from Uber and Lyft: Increased Automation and Smarter Regulations can go a LONG way!

A new Study found that doctors believe EMRs may help with reporting, but that they do NOT help with outcomes. Furthermore, they note the downsides of EMRs include increased costs and distracting from direct patient care. 

However, I think an equally guilty culprit is the over-regulation of our medical system- including 

(1) The amount and detail in which everything needs to be documented, and 

(2) The amount of extra work that doctors now need to "review and sign off on". 

On one hand, EMRs actually may help with doing some of this documentation (if we were still on paper, there is no way docs could do all the documentation required these days!). On the other hand, EMRs have also caused extra work due to their inflexible design requiring both multiple clicks to find or complete tasks, as well as enforcing a "top of license" mentality that means a doctor has to be involved with EVERYTHING.

Meanwhile, both state and federal regulations make it incredibly hard to automate or delegate even routine primary care... we are so behind other industries, and even behind other areas of healthcare! For exampe, we somehow allow AUTONOMOUS CARS and SURGICAL ROBOTS, but we have regulations that don't allow a computer to automatically handle refill requests, order labs or manage minor medication changes?!?  We think making a well trained and time-strapped primary care doctor scour an EMR and do refills at the end of the day is better than using automation to handle this type of work?  

Fortunately, there are companies like healthfinch building out tools to work within EMRs to delegate this type of routine clinical work - meaning they automate everything to the last foot... but still have to hand it off to a nurse or similar professional to click on the final button.  The result is that: 

1. It takes work off the doctor's plate (the Swoop Refill Product alone saves them 20-30 minutes a day). 

2. It makes the delegation process to nurses much more efficient (usually 3-4X more efficient, which means you only need 3 nurses to support a task vs. 12 nurses... saving millions a year, and allowing you to deploy those nurses elsewhere)

3. It improves the quality of care for the patient... both in making the turn-around time faster, and in ensuring that evidence based rules are used to make a decision

But ideally- we really need to see a regulatory system that allows us to automate the process fully!  Then instead of complaining about EMRs - docs and nurses will actually love how it make their lives easier (while also improving patient care in a variety of ways), rather than feel like the EMR is the hammer bringing down the pain on them!

I was pleased to see the recent CMS announcement that they are lauching a pilot initiative with the goal to "reshape the physician experience by reviewing regulations and policies to minimize administrative tasks and seek other input to improve clinician satisfaction".  Amen!

The other, potentially simpler, idea I would recommend is simply to provide more guidance on current regulations around licensure. For example, every state has regulations about who can do what in a healthcare setting - often convoluted language that makes it unclear if a nurse or medical assistant can do nothing, something or many things based on protocols and standing orders.

Unfortunately, every hospital system has a cache of lawyers who may interpret the laws differently because there is no "case law" they can point to for a definitive understanding.  The result may be wild swings in how one healthcare system allows work to be shared across a team.  In a world in which we need more team based care, these types of "legal traps" make it much harder to try to use everyone to the "top of their license" when that very definition is confusing.

What if a state could provide specific examples with their regulations - for example, making it clear if an MA could sign for a refill based on an automated protocol vs. requiring it to be an RN, pharm tech, or in some systems- insisting only the doctor has the power to do that final touch.  As I've often said, we don't have a shortage of physicians, just a shortage of using them efficiently... and this is a big case in point.  Doing this right allows us to share the care across the team... doing it wrong means burdening the doctor with routine care that overwhelms and burns them out.

Hmmm... Maybe Uber and Lyft should take over healthcare - as they certainly have figured a way to work around "regulatory hurdles" that allowed them to use technology to make life much easier, cheaper and better for so many! 

HIMSS 2016 (Las Vegas)

The world's largest healthcare IT conference is about to take off again Feb 29-March 4th. It's the Healthcare Information Management & Systems Society (HIMSS) Annual Conference:  http://www.himssconference.org/

Someone asked me recently why I go and what I get out of it, the answer always seems to boil down to these two things: 

• Connecting with colleagues and others; Hearing and Seeing what others are up to
• Viewing latest and greatest on the exhibit floor, while watching/listening for themes

What will be the big themes this year?  

There always seem to be a few- here is my guess as to what we will see a lot of this year:  

• Telehealth: everyone is jumping in these days, whether we are ready or not! I think the hype around "video for everything" is peaking, and then we will realize that using video for routine care perpetuates an inefficient system - and is not our way out of this mess of a healthcare system.  Over time, video will just focus on specialized care for remote locations; and asynchronous care will rise for routine care. 
• Predictive Analytics: Last year the work "Analytics" was everywhere.  I think this year it will be more focused and solutions based, with "Predictive" leading the charge. It is amazing, but everyone says they can do this better than the other guys... but there is no winner yet.  Of course, predicting who will do poorly, and being able to do anything about it are very different things!  Will be looking for companies that can do the latter as well!   
• Innovating with IT: Now that most places have a stable EMR and HIT foundation in place, and we are more quickly moving from volume to value based care... The most innovative organizations will be building on top of these platforms - either by creating tools themselves, or integrating with 3rd party apps.  Looking forward to talking about this at the AMDIS/HIMSS Physician Symposium, as well as attending the HX360 "conference within a conference".  And of course, you can still find my book on this subject (Innovation with Information Technologies in Healthcare) as the topic heats up! 
• Doctor Burnout and the Need to Make IT more Usable.  This will span from tech ideas to research reports to policy discussions. Hopefully it will not just be talk - and we will see more solutions that actually help.  I'm looking for full people/process/technology solutions which automate routine care, and/or virtualize services out of the office - but do it all in a way that takes work off the MD's plate, not adds onto it (as we have too often allowed HIT to do in the past).  Companies that fit this bill include healthfinch (which I co-founded five years ago specifically to help automate routine physician work) and healthloop (and others that are helping with post-visit care).  Additionally, I'm intrigued by the remote scribe companies (there are many now)- I need to figure out if they will really make things easier or not for PCPs.

I always keep notes at HIMSS, and am going to start "dumping" them into this blog - hoping they provide some value to me others in the future...look for an update after March 4th!  In the meantime, feel free to follow me @drlyleMD

Advice to Healthcare Startups

Like many in my role, I am constantly pounded by young entrepreneurs with the "next great innovative idea for healthcare".  I appreciate their energy and enthusiasm, and in some cases they really do have something cool and special.  However, I do find myself repeating many of the same thoughts and "rules" - so I thought that I would put some down on paper to prepare them ahead of time.

This is in part inspired by an GREAT blog by Todd Dunn (Director of Innovation, Intermountain Healthcare Transformation Lab):  The Seven Deadly Healthcare Startup Sins (and his follow up advice).  The summary:
Sin 1: Healthcare startups assume hospitals will let them host patient data in “their portal.”
Sin 2: Startups assume that clinicians will be willing to access yet another portal for their data.
Sin 3: That one doctor or hospital lends enough credibility for other organizations to simply accept a startup’s solution.
Sin 4: Believing that ONE key leader inside a hospital is the decision-maker, influencer, etc. all in one role….
Sin 5: Thinking that conducting a “proof of concept” and/or pilot is a simple endeavor.
Sin 6: There isn’t anyone else out there solving the problem.
Sin 7: Believing that startups need to have more answers than questions.

His Advice:

• Use the Lean Startup tools! Regardless of where you start, it comes down to your value proposition as a starter or non-starter. 
• This often tries the patience of entrepreneurs. I cannot overemphasize the need to use the learning loop in every single part of the Value Proposition and Business Model canvases. The only way to do that is to GET OUT OF THE OFFICE!
• Be curious about workflow  - Be empathetic to your user.
• Study the industry more deeply. While you may have a great value proposition for one or two hospitals, how does your solution fit into the regulatory landscape, workflow, etc. of multiple hospitals?
• Listen! Assume you don’t have enough evidence to scale your business yet. Act like you don’t know enough. While an entepreneur’s “go get ’em” attitude is appreciated, it isn’t appreciated when the entrepreneur isn’t open to feedback, seems to have all the answers, and has a condescending attitude toward the way “jobs” get done today. Test your assumptions! Come loaded with questions that are related to your assumptions.
• Last but not least, structure a learning plan. Embrace the Lean Startup tools and methods. Following this structure will cause you to write a learning plan. A foundational question to guide your learning plan in every part of your business model is “What do we need to learn before we invest more time and money?”

Some thoughts and Rules I would add to enhance the above

• There are basically no new ideas... a successful startup understands it is about execution.  So please don't tell me that you have a brand new idea and want an NDA because the idea is so priceless and if anyone else finds out about it they will copy it.  If it's that easy to replicate, then you really don't have a business.  I remember years ago when I was being mentored by the great informaticist Dr. Bob Greenes.  He took me into his office and showed my his PhD thesis from around 1966.  This was the dawn of the age of computers, and in his thesis was basically every idea we are now hearing from "startup" companies daily - computer guided interviews and diagnosis, telemedicine, artificial intelligence to read notes, etc...   The key is rarely the idea, but how you combine the right people with the right technology and the right timing to make it all work.  Bill Gross had a nice Ted Talk on the topic of "The Single Biggest Reason Startups Succeed".  So convince me you really understand a problem and solution well and that you can be THE company that executes on it better, faster, cheaper than anyone else!
• Truly understand and be able to explain your "Value Proposition" - specifically, clarify (1) Who Pays for your tool, (2) Who Uses your tool, and (3) Who Benefits from your tool.  In healthcare, the incentives are often not aligned - and the smart startup will fully understand and have a business plan that makes sense.  Nothing turns me off quicker than a company that expects a doctor to pay for and use a tool, when all the financial benefit then accrues to another party.  
• Bring me a solution, not just a tool.  A lot of startups are talking about how they use "big data" to identify problems and opportunities for improvement.  That is nice, but the truth is we have a lot of low hanging fruit in healthcare- I don't need to find more problems as much as I need solutions.  So if all you are selling is a way to find more problems, that will not resonate as well as a packaged solution that also "fixes" them.   For example, the analytics vendor  HealthCatalyst is soaring because they realized that they need to use analytics to identify both the problem and the potential solutions to be successful.  Another interesting company, Transfuse Solutions, combines analytics and process improvement techniques to focus on the specific issue of identifying when a hospital is doing too many transfusions and then offering solutions on how to improve on those metrics. 
• Be committed... healthcare is not for the faint of heart.  This is a big business, with long sales times, difficult implementations and hard change management.  When something works and can improve efficiency, quality and financials at the same time - and can scale well... then you will have a winner, but nothing happens overnight like in so many other industries.  So don't tell me how you have a part-time CEO, and you are out-sourcing all your IT work so some guys who have other jobs.  That is not going to build a company which has the DNA needed to succeed in this industry - show me executives and staff that wake up every day obsessed with fixing a specific problem, and an IT team that understands the nuances of healthcare and can react quickly to solve issues. 
• Make it easy to do the right thing, especially if this is doctor facing.  I often say that the best healthcare IT can make life easier for doctors and better for patients at the same time.  Do not try and tell me how "this system only asks the doctor to spend one more minute for each patient" - we don't have one extra minute!   We want you to tell us how you save us time from mundane tasks so we can have more face to face time with patients - that is what will win our hearts and minds!   This post from last year explains this thinking further: http://drlyle.blogspot.com/2014/11/the-three-keys-to-solving-our.html

So yes, please keep innovating and trying to make things better.  Our current healthcare system is clearly not sustainable as it stands, making for a "target rich environment".  But when pitching to busy providers and healthcare organizations, remember that their plate if often very full - so have your value high, your proponents lined up, your story straight, and your team ready to truly make a difference in the lives of both providers and patients.


Addendum: List of Other Relevant Blogs and Advice for Startup Entrepreneurs

• How Famous Start-ups Were Started (ScoopWhoop.com, 6/15)
• Six Reasons Why Digital Healthcare Startups Fail (1/17)

Six Lessons in Health IT Innovation

I speak frequently on the intersection of HIT and Innovation.. especially around how can we be more innovative in using the HIT we already have in place via human centered design thinking ("ask, observe, think and feel" about what the end user has to deal with).  At a recent healthcare conference, I spoke about this topic based on a combination of my own professional experiences as well as learnings from the book I wrote about the intersection of HIT and Innovation (see this post and check out www.TheHealingEdge.org).  I didn't realize that a reporter was in the room, but was pleasantly surprised a few days later when a nice article came out summarizing my "Top 6 Lessons in HIT Innovation".   A listing of these lessons is below, along with some expanded thoughts and examples: 

1. Identify the minimal viable innovation. Don't be afraid to borrow ideas from other people. "Fail early, Fail fast, Fail often and Fail cheap."  I often give the story of three organizations in the book all talking about the same issue (how to use their EMR to automate and delegate some routine preventive maintenance and disease management care).  Each organization had a different EMR and a different workflow, but the end result was similar- they figured out how to use the EMR to empower their staff to do more, resulting in a more efficient system with better quality.  The idea thus is not to exactly copy what any one of them did, but to understand the essence, and figure out how you can make it work at your organizations. 

2. People and processes are more important than the IT. Do not except technology to be a silver bullet. The people and processes behind the technology will be the forces that drive innovation.  So many of my best "innovations" are the result of creating some content and workflows to take advantage of having a single communication tool (the EMR) that links everyone in an organization and allows for creation of consistent templates and routing... which allowed us to set up a care coordination system all the way back in 2008 which resulted in better experiences for patients and providers along with better, faster and cheaper care (we even published on this data).  In the book, we hear other examples, such as how Children's National used their EMR to identify signals that indicated an "adverse events" had happened the night before (e.g. a low glucose, use of Narcan)... that was the easy part.  The more important solution was having a dedicated nurse reviewing that data every day, tracking down what happened, and working with a team to minimize it from every happening again... with spectacular results.  Another story involves the use of a ubiquitous technology Skype) to enable multiple hospitals across California to enable the concept of "virtual translators" across their disparate systems.  So even though these were all separately owned, the hospitals could "borrow" translators from each other and thus all ensure they had enough of the right language.  The innovation was less in the technology, and more in the idea- as well as the business agreement they had to set up.

3. You can start small. Innovation in health IT does not have to mean something big and radical from day one; In other words, little bets make for big wins. For example, we used a pilot of 5 iPads on the inpatient oncology floor to explore what happens if we offer free use of them while patients are "confined".  We immediately learned about workflow (how to distribute and track and clean the devices), as well as network issues we had to address as the top use of the iPads was to use FaceTime or Skype with friends and relatives... a use case we did not realize would be so popular.  The result immediate patient satisfaction as well as a much better understanding of what it will take to roll out a bigger effort in the future. 

4. Apply new innovations to old problems. This is about using some established innovation methodologies to really rethink how we practice healthcare.  I said "We are cutting the cost curve, but not as much as we need... and we must innovate or we will lose." An example I gave was use of "Video Ethnography" to better understand poorly controlled diabetics.  Working with gravitytank, a local innovation consultancy, we spent 2 hours with 8 separate patients and were able to understand this population in a whole new way.  We condensed their videos into a 20 minute summary which was used as a kick off for a half-day brainstorming session that created a slew of ideas that resulted in new ways to educate both patients and providers about diabetes (we moved away from trying to scare them and towards simplifying the message). 

5. Try different ideas and technologies that have found success in other industries. Thought leaders consistently point out that healthcare is fell behind so many other industries when it comes to technology and innovation. Try ideas from the airline or retail industries; perhaps one of these will spark rapid innovation in your organization.  I'm a big fan of "Innovation Safaris", also called analogous observations, in which we spend time in another industry to understand how they view quality or satisfaction or efficiency... and see what we can learn and bring back to healthcare.  I am fortunate to be part of a group (The Innovation Learning Network) in which we do this together every 6 months.. here is good write up of what it can be like. 

6. Embrace the power of physician happiness. Physicians can be both the source and users of innovation, but without them technology cannot go very far. "There is no quality without use" is a quote I've been using for many years in explaining that creating super-complicated systems might look good on paper, but they will not provide any real benfit if your end users are not using them in everyday practice.  Rather, we need to think about how we can use HIT to "Make life easier for physicians, while also making it better for patients". 

Perspectives on the Future of Healthcare and IT.. a Video Interview

I was recently "Video-interviewed" about my thoughts on the future of healthcare and IT.  These types of interviews are usually quick - two questions, five minutes... hopefully some value!  Here are my two questions and a summary of my answers:

Where is the healthcare industry headed?
I believe healthcare is currently a runaway train with an unsustainable model.  But there is hope if we can adapt reimbursement models to incentivize value over volume, and use HIT to simplif, automate and delegate all the care that needs to be done.  With respect to HIT, since over 80% of physicians have an EMR in place, we now an infrastructure or platform on which to build "EMR Extender Tools" which allow for better EMR functionality, efficiency, and effectiveness.  Furthermore, we need to focus HIT efforts on Population Health, Virtual care, and Workflow Efficiency to meet the increasing demands for care that are upon us.  With respect to population health; ACOs and other types of volume-based to value-based reimbursement changes will make it easier and financially viable to really manage the health population well - but we need the right HIT tools to risk stratify the population and then manage them more easily.  Meanwhile, we should see a rapid expansion of virtual care as technologies and demand sync up. Lastly, as physicians (and staff) are burning out quickly, using HIT to create workflow efficiency by simplifying, automating delegating care, is vital to the performance of doctors, as well as the health of patients (which is why I helped found healthfinch to build software solutions that allow medical groups to redesign care more efficiently and effectively). 

What is an HIT Innovation you would like to see happen soon?
I think we are getting closer and closer to “ubiquitous monitoring.” Wearable devices are available, but right now these are often just used by the “healthy and wealthy.” Although this is a good starting point, there is a need to develop patient monitoring tools that are fully ubiquitous - so that collecting biometric data becomes a simple byproduct of everyday life.  These may start as being embedded in smart phones, and now we are seeing them woven into in clothes, but soon we will have watches, patches and even injected nanotechnologies. As these evolve, doctors will be able to receive regular, real-time monitoring of their patients. From there, one can feed data into a rules engine to notify doctors (or even patients themselves) if something is medically wrong. This portends a fantastic future for remote monitoring so that doctors do not have to rely on patients to manually input data all the time and wait for them to come into the office to explain there is a problem.

The Three Keys to Solving our Healthcare System are Getting SAD, FAT and Innovative!

I was interviewed by a new magazine called Healthcare Innovation News for their September 2014 issue and they asked a lot of interesting questions - so below (a slightly editedversion) to learn about the following: How did my career path wander from engineer to doctor to entrepreneur; Why the future of the EMR rests on innovators; Why healthfinch is called The Doctor Happiness company & why we started with automating the medication refill workflow; and finally - What are the three key components to solving our healthcare system (hint - getting SAD and FAT are two of them!).

Q:   Did you plan to become involved in healthcare technology when you entered medical school? What was the impetus and what does it take for a physician to become a health information technology (HIT) entrepreneur?

A: I liked both medicine and computers growing up, so I studied Biomedical engineering at the University of Pennsylvania, where I wound up programming and working with a variety of PhDs and MDs. When I went to the University of Illinois College of Medicine, I was fortunate to have a mentor in Arthur Elstein, PhD, who had founded the Society for Medical Decision Making and created our med school's initial Informatics Department.  I became his research assistant, worked on a variety of informatics projects and realized that I wanted this to be part of my career. 

Over the years, in addition to being a PCP, I accumulated a diverse set of technology and business experiences, from serving as the Medical Director of IT for a large primary group to starting a consulting company to serving as the Chief Medical Officer for two publicly traded companies in the IT space. Then in 2008 I was able to merge technology and innovation when I received philanthropic funding to start the SzollosiHealthcare Innovation Program at Northwestern, and have been able to learn a whole new skill set of design thinking and methodologies.

Over the years, I also advised a number of startups, but eventually realized that to make the biggest impact (and have the most fun), I should be starting companies myself.  I knew I could bring an interesting variety of real world clinical, IT, Innovation and business skills to certain healthcare problems, but quickly learned that the key to success is always finding great people that can execute on a vision… and I've been very fortunate in finding the right people with which to partner.

For physicians interested in being entrepreneurs, my advice is to try and get a good variety of experiences, and then become part of a team so that you don't have to give up your "day job" of seeing patients.  You will find that keeping your day job will help financially during the early times, will allow you to add in more real world flavor to your company, and will satisfy a part of your soul that only taking care of patients can do.

Q:  Do you still believe that the electronic medical record is dead and that instead, innovation in HIT rests on apps?

A: I do believe that "EMR version 1.0" is dead, in the sense that this early vision of the EMR was mainly focused on putting data into electronic media for legibility and easy access, with an overall bias towards billing and compliance rather than making clinical care easier and better.  And while those were important building blocks, the result has been difficult to use EMR systems, especially in the primary are arena. 

So now we are evolving to EMR 2.0, where the classic EMRs become the platforms upon which innovators can build an amazing variety of apps that fulfill every doctor (and patient's) dreams!  Imagine what might happen if thousands of programmers were able to easily build "EMR Extender Tools" on top of (or within) all the EMRs which are deployed… how many great apps might we see that would never come from the traditional vendors because there are simply too many ideas and not enough time. 

Already we have seen a surge in EMR Extender Tools which provide content, decision support, and analytics programs.  And we are now starting to see apps that focus on truly improving the workflow of care to create both major efficiency and quality improvements. Ideally, future EMR Extender Tools should have enough flexibility to adjust for multiple styles and types of care, whether supporting a Cardiologist in California, a Rheumatologist in Rhode Island, or a Neurosurgeon in Nebraska.. 

We are also seeing that some EMR vendors have started to readily embrace this concept of being an open platform, while others have been slower.  But I suspect all will come along because in the history of technology, a well known truism is that "closed wins early, but open wins late". 

Q:  Why did you decide to focus on medication refills when creating your company healthfinch? How does streamlining the process affect population health?

A: We wanted to start with a workflow which affected the majority of primary care doctors, but one they would happily "give up" because losing it was non-threatening both clinically and financially. The medication refill process was the perfect scenario for us - it is a constant chore for any PCP, with the average doctor getting around 15-20 requests a day, which takes up to 30 minutes of their time to properly manage, and they never get paid for it!

We thus created RefillWizard as a workflow automation tool that intercepts any incoming refill, reviews it in a cloud-based rules engine, routes it to the appropriate person (e.g. RN, Pharm tech, MA) and instructs them on how to handle it.  With this tool supporting care redesign, the doctor then only needs to be involved in the 10-20% of refills where their judgment is truly required.  This made for easy adoption since it actually decreased the amount of work for physicians.  Additionally, we found that that the quality of care could actually improve due both to the speed of answering refills and the consistent use of evidence based rules. 

Our philosophy is actually a very different take on population health.  Rather than focus on computerizing the 20% of care which is most complex, we instead focus on building tools to automate and delegate the 80% of care that is relatively routine. This has two implications for population health. First, since physician time is a HUGE commodity for population health programs, freeing up their time from routine, repeatable tasks allows doctors to take care of a higher volume of patients, focus more on high risk patients, and/or simply catch their breath and keep their sanity. Second, by using the med refill process as a model for how to centralize and standardize certain workflows, we help create the type of team-based infrastructure and culture that will be needed in the future to efficiently manage large populations. Refills first, then other workflows later!

Q:   Why is healthfinch called the “Doctor Happiness” company?

A: In other industries, it has become clear that making the front line workers happy invariably results in better products and service to the customers (think Southwest Airlines, Google, or read Shawn Achor's "The HappinessAdvantage").  Healthcare should learn from these lessons, and we strongly believe that by focusing on creating tools which make doctors happy, the patient will invariable benefit as well.  In fact, a recent article (From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider) strongly suggests that we should expand the Triple Aim to include physician & staff satisfaction as soon as possible.

We believe in this deeply, and so one of healthfinch's driving mantras is to Save our Primary Care Physicians, and we do this by waking up every day thinking about how to use HIT to make life easier for physicians and better for patients.  In other words, this is not your normal healthcare software company.  Our first goal is to literally improve doctor happiness (without hurting quality of course). And at the same time, we believe we can "sneak in" a variety of quality improvements by helping to ensure consistent use of evidence based guidelines in routine workflows (and ps, doctors are happier when quality goes up as well).

I think that EMRs have gotten a bad rap as always creating more work for physicians.  Of course, that should be no surprise as the traditional EMR vendors are understandably focusing on functionality that is mandated by various regulations (i.e. documentation and billing and MU) over holistic usability.  And that is a problem since no matter how good a function might be, there is no quality without use, and there is no use without usability.  However, I believe that the Golden Era of using HIT to lessen the workload for physicians is just around the corner!  . 

Q:  What are the three key HIT strategies physicians should adopt to improve healthcare delivery?

A: First, we need to optimize our use of HIT to make doctors much more efficient and happier.  I call this Get SAD to Make Doctors Happy:

• Simplify their interaction with EMRs, such as by minimizing their direct hands on experience (e.g. scribes, voice recognition, Google Glass) or using data visualization to help make the cornucopia of data easier to view and understand
• Automate as much of the workflow as possible
• Delegate the things that can be delegated to the appropriate person on their team

Second, we need to better manage large populations of patients. I call this Get FAT to make the Population Healthy:

• Financial incentives need to be aligned around volume rather than value
• Analytics will be used to risk stratify and understand our populations better
• Team based care which will spread the workload appropriately across all the members of the team.

Third we need to devote time and resources to being more innovative. I call this The Three EEEs of  Innovation:

• Explore new technologies and thinking to get some insight and ideas on what you might do and how you want to prioritize
• Experiment by building prototypes and pilots to test new ideas, care models and technologies.  Iterate often until you have both a good clinical use case and business case.
• Expand the innovation to the rest of the organization

If we can do these three things effectively, we will find that we don't really havea shortage of physicians, just a shortage of using them efficiently. And the future will be one where the typical physician sees less patients face to face, but is able to take care of more patients every day using an IT empowered, team-based approach that utilizes everyone to the top of their license and improves the quality and experience of care for both patients and providers.

Hacking to Innovate and Engage: Why Hackathons Will Change Healthcare for the Better

In today’s post-reform world, we hear time and time again that there is (or soon will be) a physician shortage due to a variety of factors.  For example, with the millions of people who now have access to healthcare services due to the Affordable Care Act and the growing aging population (with their increased risks and needs) – it’s no surprise a potential physician shortage is a regularly addressed topic.  However, I still strongly believe that we do not have a shortage of physicians, just a shortage of using physicians efficiently (see past blog).

As a PCP who has been taking care of patients for over two decades, I know firsthand that the amount of hours in a day is never enough to accommodate all we want to do (we often get caught up in fire drills, and can't get to all the preventive and chronic care management we would ideally address).  Fortunately, I do believe that by combining technology, innovation and teamwork, the potential to simplify, automate and delegate care for a more efficient care delivery process exists, even if it’s not always easy to accomplish.

In this blog, I want to touch on what some consider a surprising way to simplify the equation and make better use of physicians and their limited time: A motivated and engaged patient. Care coordination can be achieved when patients and physicians are aligned throughout the care continuum, creating a more succinct care delivery process. Studies show an empowered patient can lead to better outcomes – and potentially lower costs – so the better we are at equipping patients with the proper care plan, the more we can alleviate some of the burden providers face caring for nearly 20 patients per day.

I recently participated in the Intel-GE Care Innovations Patient Engagement Hackfest as the closing keynote speaker and a judge. The purpose of the event was to solve one of the biggest hurdles in healthcare today: connecting patients to their health and healthcare providers through better engagement. Not an easy feat. The major challenges I see are: 

•          Behavior change is hard
•          Incentives are misaligned
•          Information overload
•         Patients spend most of their time outside of the office or hospital setting

 That last point may be the most important to any physician out there. The disconnect is real, and the ability to influence overall health is limited. So how do we – healthcare leaders, physicians, innovators and disrupters alike – continue to push the envelope further for a more connected healthcare system? In writing a book on the intersection of HIT and Innovation, I found some pretty consistent themes on how to innovate in a healthcare environment, which I would summarize as follows: 

•          Have a champion with passion and knowledge
•          Listen to and observe the front line
•          Start with crazy, out of the box ideas, then make them realistic
•          Fail Fast, Fail Small, Fail Cheap
•          Figure out a sustainable business plan
•          Spread your idea with the IT systems in place

Hackathons incorporate many of these concepts in a tightly focused and concentrated manner. They are a fertile ground for giving life to innovative concepts and inspiring people to develop healthcare’s next generation of solutions. The Intel-GE Care Innovations Patient Engagement Hackfest brought together passionate and inspiring people – from entrepreneurs to programmers to clinicians – who shared ideas and resources to make the patient the most important part of the care team. And that’s a worthy cause to get behind.

Be on the lookout for a hackathon near you! 

Defining Healthcare Innovation

In my recent post at Clinical Innovation + Technology, I tackled the issue of defining "Healthcare Innovation".  I decided to do it by answering the typical questions I often hear, and so hope this helps you in explaining to others!  Below are my answers, with a bonus answer for my blog :)

One of the most common questions asked these days is “What is healthcare innovation?” Like the story of the blind men touching different sides of an elephant and each describing something separate, you will hear a wide variety of answers to this question based on whom you ask.

The following is a way to address the common questions on this topic so you can start organizing innovation in your mind and within your organization.

First, should the focus of innovation be on innovative information technologies, devices, workflow processes, care models or business models? Obviously, it can be any or all of the above. In the past, it is fair to say the majority of innovation work was in the devices arena since there was a clear financial return to the organization if a new device was widely adopted.  However, in a world changing to value-based reimbursement, we are seeing that process and care model innovations will likely be leading the charge, with information technology being an enabler of those innovations.

Second, how is an innovation project different than an improvement project? The short answer is that an improvement project is done to improve something, while an innovation project is done to blow up the current process or tool and create a new one. A classic example of this is polio: improvement experts would focus on designing a better iron lung, while innovation experts would consider how they might create a vaccine to stop this disease in the first place.

Third, is there a science or methodology to doing innovation well? Yes, similar to how improvement projects may use techniques like Lean and Six Sigma, the world of innovation relies on the concept of “Design Thinking” which has a different set of methodologies. The typical innovation project involves three main phases: discovery, incubation and acceleration. In the discovery phase, a problem is studied and observed and then various brainstorming techniques are used to create potential solutions. In the incubation stage, rapid cycle prototyping and piloting are done to quickly and cheaply find what fails and what works. In the acceleration phase, the successful pilot is spread using a variety of educational and other techniques.

Fourth, do all innovators need to use this formal science of innovation to succeed? It’s fair to say that many of the innovations we see in healthcare were done without formal innovation methods.  Rather, innovation started with a passionate individual or team trying to solve a problem with which they had a deep understanding. They would try various iterations until they got something that worked and then maybe spread it to others. However, the creation of an innovation culture and infrastructure to support a formal process of design thinking is likely to help identify more of these projects and make them more successful.

Fifth, what helps make up a successful healthcare innovation? First, it always starts with a passion for making something better plus some time and resources to focus on the project.  Second, it needs to have a real-world business model to keep the innovation sustainable. Third, the innovation needs to be well integrated into information technologies and clinical workflows so that it can be easily spread. Not surprisingly, it is this last part which is always one of the hardest and yet most important pieces. And it is why this intersection of information technology and innovation remains critical to the success of evolving our healthcare system to meet its potential.

Bonus question: What is the difference between a sustainable and a disruptive innovation? Sustainable innovations are those which sustain the current business model (e.g. things that promote volume in a FFS environment) and/or which add on features/functions with an increasing cost (e.g. the new MRI machine). Disruptive innovations are going to change the business model, often by offering same or less features, but at a much lower cost (e.g. TeleDerm visits, Nurse-managed protocols for Diabetics, a hand-held cardiac ultrasound which gives you just the heart information you need to make a clinical decision).  A recent article from the Clay Christenson Institute reviews Why EHRs are Not (yet) Disruptive.

Clinical Innovation & Technology Article Link: Defining Healthcare Innovation

The Hat Trick: Physician + Informatics + Innovation

Looks like June is Q&A month for me!
Here are three recent interviews and articles where I answer questions about Healthcare IT and Innovation:

When Health IT Meets Innovation: Q&A With Dr. Lyle Berkowitz of Northwestern Memorial Hospital (Becker's Hospital Review)
This interview focuses on lessons learned from my book (Innovation with Information Technology in Healthcare) - so I review the history of the book, mention a few of the stories, discuss the biggest "takeaway" (get inspired by others, but modify innovations for your own organization), and explain how to start innovating right now!

5 Questions For… Dr. Lyle Berkowitz (The Intel Health Blog)
This interview is more broad-based and we talk about how to change an organization's culture towards innovation, more lessons learned from my book, where healthcare innovation is heading in the coming years, and What is the Szollosi Healthcare Innovation Program.

The Hat Trick: Physician + Informatics + Innovation (Clinical Innovation and Technology)
This is my monthly article as "Innovator in Chief", and I talk about one of the most common questions I am asked - how to balance clinical care, informatics and innovation.  Full text is below:

I am a practicing physician with extra responsibility for informatics and innovation. I love being able to do multiple things in my day, but I do often hear “How do you juggle all those roles?”  The simple answer is that I truly treat them as synergistic—they feed and support each other. My first love is being a primary care physician and taking care of my patients. Yet I also am constantly thinking about how I might do my job easier and better.

Sometimes there is an informatics answer, such as creating new content, alerts or reports within our EMR. Other times there are more innovative answers, such as creating a new process which helps delegate work across my team. But increasingly, there is a combined answer, such as creating a new workflow within our EMR or finding an innovative IT tool and figuring out how it fits into our system’s infrastructure.

Physician informaticists also ask me is how they can be more innovative. The good news is that most informatics doctors are perfectly set up to expand into the innovation space. They already have an appropriate skill set, such as an interest in new technologies and workflows, excellent problem-solving talents, an ability to work with a wide range of personnel, and an innate desire to constantly improve the current system. The trick is whether they have the time and resources to make these changes happen, so here are some thoughts to help you blaze this trail at your organization.

First, start small and let things evolve. In fact, a well-known innovation mantra is “Fail Fast, Fail Cheap, and Fail Often.” In other words, you should embrace piloting and the concept of an “n of 1,” often where you can and should be your own guinea pig and ground zero for your innovations. This means signing up for the many new apps, websites and technologies you see out there, healthcare related or not. Try them all for a little to see what they feel like and think about how they might apply to healthcare. Maybe come back to them at another time if you don’t see the value at first. Be the first to try new EMR functions to determine how well they might work in your system’s current workflow, or if they warrant a new workflow.

You will fail. A lot. That is okay, because each mistake is a golden piece of information which will help lead you to a better place. By starting small, you don’t need a lot of time, resources or permission to try something new.

Second, always make time to observe. Just watching your colleagues and staff in their day to day lives will help you quickly see bottlenecks and gaps. For example, I was approached by our hospital nursing executives recently as they were trying to be innovative with the discharge process. We formed two teams of three people each and went to the floors to observe and talk to the frontline staff—the nurses and other caregivers on the floor. We used a classic innovation method called “Love/Wish,” where we ask folks what they love about a process and what they wish would change to make it better. An hour later our two groups met and found we had a robust list of opportunities that involved improvements and innovations to both workflow and IT utilization.  

Being a physician informaticist gives you a unique platform upon which to innovate, so keep your eyes and mind open and help make a better system for all of us.

A Call to Action for HC Innovators: Do the Easy First (and then Google Glass)

At HIMSS in March, I loved hearing Dr. Eric Topol's keynote talk about the Creative Destruction of Medicine, and how future technologies like genomics and nanotechnology will make diagnosis and treatment so much better and easier.  And then last month, I read Travis Good's HISTalk story about "The Power and Hype of Google Glass", and searching online, I found many more:

• How Google Glass Could Revolutionize Medicine  [iMedical Apps]
• How Long Until Your Doctor is Wearing Google Glass?   [Venture Beat]
• Potential Medical Applications of Google's Augmented Reality Project  [Medical Electronics Design]
• How Will Google Glass Change The Health Space?   [MedCrunch]
• Google Glass and the Future of Medicine   [HL7 Health]
• Google Glass Features: How Medical Uses Will Revolutionize Your Healthcare  [Video at Medical Daily]

It got me to thinking that there are so many cool and futuristic things we can (and should) be doing in healthcare.  However, if all the best thinkers are focusing on the "future" - who will be focusing on the present?  By always coming out with new technologies, we seem to have created a "time-shift brain drain", which means we may not be focusing on how to improve or innovate with the stuff we have RIGHT NOW.  It might not be as fun to optimize the slow, clunky "EMR 1.0" we use today, but it is important, and will help free up time for doctors and others to actually take a breath and do what they are good at (e.g. higher order thinking) rather than the rote, repeatable tasks which have to be done every day (e.g. med refills, reviewing every single lab, documenting every single action...)!  And this is especially important as a new study illustrates how "time constraints make it harder for physicians to solve the medical mysteries that confront them".

So it led me to write my May "Innovator at Large" column in Clinical Innovation + Technology, it's called "Do The Easy First"... which is a "Call to Action" for healthcare innovators everywhere to start thinking about both the present and the future... as it will be much easier to evolve our healthcare system if we make sure it does not go extinct first!

Do the Easy First (April 24, 2013)

I love reading about advanced technologies that have the potential to help with our most complex patients. It will be a fantastic future where natural language processing mixed with big data analytics will help diagnose difficult cases and suggest novel management strategies.

A future where Google Glass will help doctors more easily recognize dermatological manifestations of systemic diseases while also providing patients with a video of their visit to the physician. And where a nanotechnology sensor floating in the bloodstream can identify DNA changes related to early cancer or heart disease and send an alert to let patients and their providers know to start intervention quickly.  

However, I am also a pragmatic physician and know that while all of this may eventually happen, I have to live in the here and now of technical and financial limitations. Currently, we still struggle to get reasonably accurate data into EMR systems, doctors are not paid extra to identify anything early and most physicians feel they are running out of steam as they spend half their time doing non-clinical, or certainly non-advanced, duties.  

I believe some innovators need a wake-up call. Instead of focusing all your time trying to figure out the hardest and most complex issues, how about figuring out the easy stuff first? For example, many physicians spend a big chunk of their day documenting what they just did, filling out administrative paperwork, trying to keep everyone up to date on preventive care and disease management protocols, and answering the same questions over and over again.

In other words, physicians are not being used at the highest level of their abilities and, thus, we have created an artificial shortage of doctors. Furthermore, physicians are not great at taking care of all this routine care and administrative paperwork, resulting in decreased quality and patient satisfaction. It’s no wonder our healthcare system is the costliest and not the most effective in the world.

But who says doctors should be doing all this work? State laws on scope of service need to be respected (or at some point reviewed for best practice). But ironically, the current use of IT has often shifted more work onto the physicians than ever before due to poorly created IT systems which were built for a physician-centric setting rather than a team-based setting.  

What if we started applying our innovative technologies and thinking to help streamline the routine and repeatable workflows which clog up a physician’s time? What if we could use automation to cut down on the unglamorous paperwork chores which are slowly strangling our physicians? What if we used HIT to empower a physician’s team to manage a large chunk of their stable patients remotely based on the doctor’s electronic care plan? What if we saved physicians one, two, even four hours a day of this drudgery so they could spend that time focusing on their truly complex patients? What if we could have a future where care could be delivered in a safer, cheaper and more efficient manner and doctors could focus their time on tasks for which their abilities are best matched?

Maybe they’d even have some time to try out that new Google Glass!

Population Health or Bust!

My April editorial post for Clinical Innovation + Technology is called "Population Health or Bust!".   The premise is that we know reimbursement models are changing from "Volume-Based to "Value-Based care", which may range from gain-sharing to bundled payments to full capitation... And thus we need certain types of tools to better manage our populations of patients.  So I defined what these population management tools should do and what to consider when purchasing them:

First, population health management means that you (1) define a specific population and (2) manage that population in the most efficient, cost-effective and highest quality manner possible.  In other words, instead of treating everyone the same, you provide the right care to the right people in the right time and in the right format. This helps to ensure that we focus our limited resources on the people who need them most, while using innovative strategies and technologies to leverage care for others.

Second, be on the lookout for some key functionalities when choosing your population management tools. These include risk stratification, impactability analysis, care gap identification, outreach capabilities, care coordination dashboard, patient engagement systems and analytics reporting.

Third, population health tools are everywhere right now, including offerings from your EHR vendor, your insurance companies and various third parties. Factors to help guide your decision will include not just the strength of their offering, but their ability to integrate into your workflow, their ability to work with multiple data sources, and their future visions. Additionally, we are starting to see interesting gain-sharing business models that may make initial investments free or cheap.

I ended my post explaining why I believe that when dividing populations into "Low, Medium, and High" risk, that the really cool innovations (e.g. mobile monitoring, telehealth, automated care) will be in the Low and Medium categories, rather than the High risk ones.  And furthermore, that this will hopefully open up more free time for physicians to spend with the "High risk" patients who needs more of the face to face care we consider traditional right now.  Said another way... let's automate the easier stuff so we can allow for more time, critical thinking and compassion for the tougher stuff! 

Companies in the Population Health Space (at least a partial list)

·         Advisory Board Company:  www.Advisory.com

·         CareMerge (focus on elderly):  www.caremerge.com

·         Care Team Connect:  www.careteamconnect.com

·         Clairvia http:  www.clairvia.com

·         Click4Care:  www.click4care.com

·         Clinigence:  www.clinigence.com

·         Curaspan (SAAS – Handoffs):  http://connect.curaspan.com

·         Essence HC:  www.eghc.com

·         EvolentHealth (UPMC + ABC):  www.evolenthealth.com

·         GSI Health (Lori Evans) (CC Platform):  www.gsihealth.com

·         Healarium (Mobile Pt Activation Apps):  www.healarium.com

·         Humedica (bought by Optum 1/13):  www.humedica.com

·         Intelligent Healthcare:  www.intelhc.com

·         Lumeris (ACO for hospitals):  www.lumeris.com

·         Medventive (bought by HBOC 2012):  www.medventive.com

·         Outcome Advantage:   www.outcomeadvantage.com

·         Patient Point:  http://patientpoint.com/

·         Pharos (Dz mgt, Randy Williams):  www.Pharosinnovations.com

·         Phytel:  www.phytel.com

·         RipRoad:  http://riproad.com/

·         See Change (Insurance and Systems for Employers): www.seechangehealth.com

·         Symphony (ACO Software):  www.symphonycaresolutions.com

·         TCS:  www.tcshealthcare.com

·         US Health Centric (Dx/Wellness mgt):  www.ushealthcenterinc.com

·         Valence Health:  www.valencehealth.com

·         Vital Health:  www.vitalhealthsoftware.com

·         Wellbe.me (Checklist based Workflows for Discharges):  wellbe.me

·         Wellcentive:  www.wellcentive.com

·         xG Health Solutions (Geisinger Spin-off):  http://xghealth.com/ 

I will edit this list over time - but it gives one a sense of how many companies are already in the space in one form or another (and this does not even include all the EMR vendors and their offerings).