Saturday, November 29, 2014

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.

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