NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

Innovation

apple storeJe n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. —Blaise Pascal

Translation: I have made this longer than usual because I have not had time to make it shorter.

As Appley as it gets.

A while ago I was challenged to write about what an Apple-like approach to healthcare might look like.

That challenge has been weighing on me.

For starters, we’re all over Appled aren’t we? Maligned anecdotes about Steve Jobs and the iPhone make their way into almost every presentation remotely related to innovation or technology. Triteness aside, I’ve been stalled because Apple is really a philosophy, not a series of steps or lessons learned. (Although, they are nonetheless methodical.)

Instead, what I’ve been kicking around in the ole noggin are three notional predictions, which I’ll assert are inevitabilities which will fundamentally disrupt healthcare delivery as we know it today.

What follows is about as Appley as I’m likely to get. Despite big-bang product launches, Apple actually plays the long game. They introduce small features into products to affect user behavior years before a flagship product takes advantage of those reprogramed behaviors.

That’s how they disrupt.

I believe there are three meaningful, unstoppable trends, in our current world which will significantly alter healthcare. The steps taken towards these inevitabilities, along the way, are what will define the innovators and leaders. They are the ones who see this future and know how to drive towards it.

The three trends are:

  • Tools and culture which favor individual empowerment
  • The commoditization and automation of diagnosis
  • Accelerated globalization of treatment options

But wait, there’s Moore.

Don’t worry, I’m not going to leave you hanging. I’ll attempt to rationalize each of these points and explain why, particularly when considered as a bundle, they are a powerful force for disruption. And to prime that pump, we have to talk about Gordon Moore.

Continue reading “Moore’s Law in Healthcare – Three Predictions”

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There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.

Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.

The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen.

I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expected to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.

A box showed up early, big deal, right?

Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site.

I believe they preemptively moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patent for exactly that process last week.

By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.

We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma.

More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?

Continue reading “Amazon.com as a Delivery Model for Population Health”

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Last week  I went to a panel presentation sponsored by the group NYC Health Business Leaders on the rollout of New York State’s health insurance exchange.  Among the speakers was Mario Schlosser, the co-founder and co-CEO of the venture-capital-backed start-up health insurance company Oscar Health, which offers a full range of plans through New York’s exchange.

As NPR reported last month in a story about Oscar, “it’s been years since a new, for-profit health insurance company launched in the U.S.”, but the Affordable Care Act created a window of opportunity for new entrants.

Schlosser began his talk by giving us a tour of his personal account on Oscar’s website, www.hioscar.com.  Among other things, he showed us the Facebook-like timeline, updated in real time, which tracks his two young children’s many visits to the pediatrician.

He typed “my tummy hurts” into the site’s search engine and the site provided information on what might be wrong and on where he might turn for help, ranging from a pharmacist to a gastroenterologist, with cost estimates for each option.

Additional searches yielded information on covered podiatrists accepting new patients with offices near his apartment and on the out-of-pocket cost of a prescription for diazepam (which was zero, since there is no co-payment for generic drugs for Oscar enrollees).

As an audience member noted, none of this is new exactly.  What is new is to have this kind of data-driven, state-of-the-art user experience being offered by a health insurer.  Schlosser told the audience that Oscar’s pharmacy benefit manager and other vendors are providing the company with real-time data that other insurers have not demanded.

 

Continue reading “Can Oscar Succeed In Making Health Insurance Fun? Maybe Not Just Yet. But the Startup Is Shaking Things Up …”

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Let’s get the disclaimer out of the way:

We love Uber.

As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.

When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)

So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.

And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.

Continue reading “Uber for Health Care?? Not So Much.”

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While your humble columnist eschewed forecasting for 2013, he  has decided to reverse course and inaugurate the 2014 blogging season with a contrarian duodecimal exercise in futurism. Will this antidecimal augury align with the mysterious cosmic order and governing perfection?  Let the readers be the judge in January 2015……

1. Obamacare will neither succeed or fail.  This hugely complex law will have too many outcomes, statistics and analyses that will be subject to too much spin by both supporters and detractors. Like puppies clamoring for the mother’s attention, the loudest wins, but only in 15 minute media increments.

2. Inflation returns, with a vengeance: While we won’t know it until well into 2015 or 2016, 2014 will be the year that the sleeping giant of healthcare costs awakens. Millions of new insureds in an improving economy will finally get their pent-up pricey preference-sensitive health care needs fulfilled.

3. Duh, it’s the delays stupid: While low income Americans will appreciate having access to subsidized health insurance and Medicaid, the middle class’ unsubsidized sticker shock will threaten the fall 2014 elections. Caught between conflicting advice of insurance actuaries and political hacks, the White House’s regulatory choices will be obvious.

4. Commercial scientific misconduct: Unable to resist the allure of bonus payments (like this) or the branding that is dependent on the public release of quality outcomes, at least one large health entity will be caught committing “reporting fraud.”

5. Snowden blow-backas the promise of big-data grows, fearful health care consumers will be even less inclined toward allowing access to their health information.  Too bad they won’t be given a say.

6. Innovator’s Dilemma for health tech: solutions that are simple, transparent and modular will continue to make ‘from the bottom’ inroads into a tech industry that - like early data storage - is too complex, opaque and entangled.

7. Speaking of health techpatient-monitoring solutions that offer more insight and less data will grab market share.  Instead of a series of blood glucose results dumped into an electronic inbox, think algorithms that suggest insulin dose adjustments.

Continue reading “Twelve Things We’re Pretty Sure We’ll See Happen In Health Care In 2014″

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Aspiring healthcare entrepreneurs could be forgiven for assuming our most significant challenge is the need to reduce the cost of care.  Investors and policy wonks alike seem to agree on the overriding need to focus on innovations that will improve efficiency and take costs out of the system.

The appeal of this approach is easy to understand: rising healthcare costs are a real problem, and business process improvement feels like something we already know how to do.  Large companies like GE and Oracle are thrilled by the opportunity to apply their process methodologies to healthcare.  Management journals love the idea of improving healthcare through operational excellence.  An increasing number of foundations have also joined the fray, focused explicitly on supporting innovations that reduce the cost of care.

Yet, as much as operational improvements are urgently needed, they should not represent the primary goal of healthcare innovation.

If we’re truly interested in high value healthcare, we’d do well to keep in mind that for many, if not most serious or chronic diseases, at least in the absolute sense, high value care simply isn’t an option.  We have embarrassingly few therapeutic approaches that can really do much to restore the lives of these patients.  Sufferers afflicted with Alzheimers Disease, pancreatic cancer, brain tumors, and so many other conditions desperately require transformative breakthroughs, not the mucking around the edges that passes for treatment today.

Make no mistake: it’s critical we do the very best we can to provide compassionate, evidence-driven care for patients who are sick right now, and innovations that contribute to the identification and humanistic delivery of the best available care are vitally important. Continue reading “Healthcare Innovation Is Not Just About Cutting Costs”

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The launch of HealthCare.gov certainly didn’t go as planned. Due to technical errors, millions of Americans were sent to the functional equivalent of a waiting room before they could enter the shopping portion of the site.

Historically, projects of such complexity and demand have encountered early problems yet still often achieve great success. While much of the commentary has focused on coding problems, the site still has the potential to spur innovation — be it public or private —  that will result in quality improvement and lower costs.

For context, the HealthCare.gov site is merely the front door to an incredibly complex technological undertaking tasked with organizing insurance plans, assessing program eligibility, facilitating consumer enrollment, managing financial services, and providing all of the associated customer support.

An estimated 19 million people visited the site through Sunday, and many did so at the same time; at peak periods, there were five times as many simultaneous visitors as had been expected. In rapid response to that surge, the HealthCare.gov team tried to restrict the number of visitors to the area of the site where they could establish accounts and begin shopping.

Naturally, this was not ideal, but it was preferable to the alternative.

When Internet entrepreneurs prepare to launch a new service, they tend to anticipate two scenarios. The first, and worst, is that nobody visits. The other is that too many people do.

Rise of a new platform

Drawing from my experience as CTO in President Barack Obama’s first term, we overcame initial technical challenges in popular programs such as “Cash for Clunkers” or the Post-9/11 GI Bill of Rights for veterans through an analysis of the root cause problems — and a systematic plan to address them.

I’m confident that the HealthCare.gov team will similarly fix the technology with the help of experienced technical talent – in and out of government – to work through its punch list. The site should continue to improve in the weeks ahead, building toward Dec. 15.

But the real story, likely to play out over the coming months, will be its rise as a new platform for innovation – one that will lead to the creation of new private sector services to improve our nation’s health.

Continue reading “What’s Next for Healthcare.gov?”

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I assume by now that you’ve heard the news: Google wants to tackle aging. Specifically, they announced this week the launch of Calico, “a new company that will focus on health and well-being, in particular the challenge of aging and associated diseases.”

Because, says Larry Page, with some “moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives.”

“Can Google Solve DEATH?” shrieks a TIME cover.

Google’s goal, it seems is to find ways to extend human lifespan and essentially stave off aging.

Coincidentally, on the same day Physician’s First Watch directed me towards this NEJM editorial, announcing that NEJM and the Harvard Business Review are teaming up on a project on Leading Health Care Innovation.

Here is the paragraph that particularly caught my eye:

“The health care community and the business community today share a fundamental interest in finding ways to achieve higher value in health care. The ultimate objective for both communities is to keep people healthy, prevent the chronic illnesses that consume a large fraction of our health care dollars, use medical interventions appropriately and only when needed, and create an economically sustainable approach to the delivery of health care. While we want to foster innovation and novel therapies against disease, we also recognize that, whenever possible, prevention of disease before it is established is the better solution.” [Emphasis mine.]

And therein lies the rub. Whether it’s Google or a high-powered partnership between NEJM & HBR, everyone is enamored of prevention and innovative cures.

Let’s prevent those pesky chronic diseases! Let’s cure aging!

Ah, spare me.

Continue reading “Who Will Solve Healthcare For Our Parents And Grandparents? Probably Not Google.”

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In Shirie Leng’s excellent post, “The Email I Want to Send To Our Tech Guys But Keep Deleting, Dr. Leng lists a series of problem areas which plague software development in healthcare. Making things better requires taking a closer look at the specs we use. The new-age consumer-focused software companies can build products with outstanding usability because they start and end with the specs.

I have spent time at several academic medical institutions, and their software solutions are very much the same. At one, I was given this five-page table of portals and documentation systems with instructions on how to log in.


The punchline: I’m asked to have a different username and password for each of them.

I give much credit to the physicians who navigate these software applications, including the one that compiled the list I showed above. But physicians have allowed poor design of their technological solutions for too long, and have neglected to demand interoperability from software vendors.

The number of required training hours is a good indicator of usability. (And many of the items on the list come with long training hours.) While physicians have accepted these courses as part of their jobs for years, why should formal training be necessary to operate an EMR? Most of the tasks of ordering and documentation are no more complicated than paying your credit card bill or shopping online.

I’ll only scratch the surface of this usability problem by highlighting several notably poor implementations. I won’t even get into the inefficiencies in ordering and documentation.

My first example is an EMR system that is used to order medications and communicate data with nurses [below]. At a glance, there are no fewer than seven distinct menus on the screen at the same time. In my experience using this EMR, I’ve clicked ten percent of these buttons (and I would estimate that 90% of the work occurs in 5% of the buttons). The poor organization of information leads to lengthy searches for the right information, and often, the unawareness of critical information that is hiding under a nondescript label.

Lesson: Menus should have clear hierarchy.

My second example is a shift-scheduling application [below]. Here is an example of of how applications can invent interfaces rather than using the ones familiar to us. The primary menu is on the left-hand side. Upon clicking on one of these options, the secondary menu is displayed right below the header. The tertiary menu, however, goes back to the left-hand side. The issue here is a lack of consistency and predictability.

Continue reading “How Programmers Think: A Doctor’s Guide to Building a Better EMR”

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NEHI recently convened a meeting on health care innovation policy at which the Harvard economist David Cutler noted that debate over innovation has shifted greatly in the last decade. Not that long-running debates about the FDA, regulatory approvals, and drug and medical device development have gone away: far from it.

But these concerns are now matched or overshadowed by demands for proven value, proven outcomes and, increasingly, the Triple Aim, health care’s analog to the “faster, better, cheaper” goal associated with Moore’s Law.

To paraphrase Cutler, the market is demanding that cost come out of the system, that patient outcomes be held harmless if not improved, and it is demanding innovation that will do all this at once.   Innovation in U.S. health care is no longer just about meeting unmet medical need. It is about improving productivity and efficiency as well.

In this new environment it‘s the science-driven innovators (the pharma, biotech, and medtech people) who seem like the old school players, despite their immersion in truly revolutionary fields such as genomic medicine. It’s the tech-driven innovators (the healthcare IT, predictive analytics, process redesign, practice transformation and mobile health people) who are the cool kids grabbing the attention and a good deal of the new money.

To make matters worse for pharma, biotech and medtech, long-held assumptions about our national commitment to science-driven innovation seem to be dissolving. There’s little hope for reversing significant cuts to the National Institutes of Health. User fee revenues painstakingly negotiated with the FDA just last year have only barely escaped sequestration this year. Bold initiatives like the Human Genome Project seem a distant memory; indeed, President Obama’s recently announced brain mapping project seems to barely register with the public and Congress.

Continue reading “Science-Driven Innovation and Tech-Driven Innovation: A Marriage of Convenience or a Marriage Made in Heaven?”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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