OP-ED

Balancing Consistency and Innovation in Healthcare

Our healthcare system is now facing a problem that has plagued business leaders for years: how do you  balance consistency and innovation?

The drive for consistency in healthcare is based upon the fundamental observation that physicians across the country treat similar medical conditions in dramatically different fashions.  Sometimes, these different approaches are costly, such as using a more expensive treatment when a less expensive approach might be as effective.  In other cases, these practice variations are dangerous – failing to provide patients with treatment the evidence suggests is best.

Standardizing the delivery of care — identifying “best practices,” and then insisting physicians follow these guidelines – could, in theory, save money while improving quality, and is the basis of Obama’s healthcare proposal.

Businesses have long known about the benefits of standardization – lower costs, higher baseline quality — and have aspired to achieve it.  The ability to make the same product in the exact same way every single time has contributed materially to the success of companies from McDonalds to Intel.  The global adoption of the “Six Sigma” program, an initiative originally developed by Motorola to reduce variability and ensure consistency, is perhaps the most visible example of the value most industries place upon achieving uniformity.

For many managers, one of the great attractions of consistency initiatives is that they offer instant metrics, quantitative methods of evaluating how well you are doing simply by measuring how close you are adhering to the established standard.

Yet, these exact metrics are also what most concern many physicians, as the drive for standardization seems to have far outstripped our ability to identify appropriate standards.  Many practice guidelines are based on limited data, and in many cases, it’s not clear that strict adherence to these guidelines actually improves patient outcomes.  (The ubiquitous use of “best practice” benchmarks in the corporate world likely rests on an even shakier foundation.)

The administration hopes that through improved communication, and aided by modernized information technology systems, physicians can be nudged to standardize themselves, motivated by a professional desire to provide the best care at the cheapest cost.  However, given both the profound challenges of defining what “best” is, and the complexity of physician motivation, the only way to achieve the required cost-savings may be to mandate strict adherence to practice guidelines.

At some level, standardized algorithms might be good for medicine, reducing the blatant mismanagement of patients by physicians who have not stayed current, and discouraging doctors from reflexively selecting expensive procedures or medications that have been shown to offer little benefit.  In simplifying the physician’s decision tree, such guidelines may also enable doctors to spend more time listening to patients, and less time running through a confusing litany of therapeutic alternatives.

At the same time, if medicine lurches in the direction of guidelines and algorithms, two important opportunities may be lost:

– First, we may lose the chance to individualize care; as Steven J. Gould famously wrote, “The median isn’t the message,” and a treatment ineffective for most patients may be enormously useful for some.  A key driver of personalized medicine is the urgent clinical need to identify just which patients are most likely to benefit from a particular drug or intervention.

– Second, we may lose the opportunity to tinker and innovate – so many powerful discoveries originated with a clinician’s chance observation or slight deviation from standard treatment.  If the role of physicians is dumbed down to the point where they are simply expected to mechanically execute on established protocols, the ability to intelligently improvise may be curtailed, thwarting medical progress.

Regrettably, the current fashion for standards has consumed not only medical practice but also medical training, as young doctors, nurses, and other healthcare providers are continously compelled to demonstrate “proficiency” in a series of expensive (and, for the sponsors, quite lucrative) certification examinations, despite minimal evidence that the score produced by this testing correlates in any meaningful way with the care subsequently delivered to patients.   In a healthcare system fixated on metrics, the proliferation of such unvalidated testing instruments will only get worse.

Is there an intelligent way to harness the cost and quality benefits of standardization in a fashion that doesn’t lead to the dangers of guidance creep and preserves innovation?

One approach is to clearly differentiate between guidelines based on the most robust evidence – strong recommendations that truly deserve to guide clinical practice – from all other guidance, which can inform care, but should not dictate it.  This will require from clinical leaders who develop guidelines a measure of humility – something often in short supply.

A second approach is to ensure that to the extent standardized treatment protocols are employed, they are routinely used to evaluate and improve care, not just deliver it.  Treatment algorithms could enable the rigorous comparison of different therapeutic approaches when there are several reasonable alternatives, potentially providing more actionable conclusions than an army of tinkering practitioners.  Success in this research endeavor would require planning, expertise, commitment, and funding (presumably also in short supply).

My own experience working with a range of companies suggests that balancing consistency and creativity can represent an overwhelming challenge.  While many managers harbor a genuine desire to promote innovation, ultimately, the allure of standardization, and the seductive comfort of quantitative metrics (however meaningless) and rigid processes (however cumbersome) is often too powerful to resist. Our healthcare system is too important to suffer this same fate.

Ensuring good data are translated into clinical practice is essential, but replacing true uncertainty with false precision will only hurt patients, inhibiting innovation while obscuring the relatively few well-established standards that have clearly been shown to make a difference.

David Shaywitz, MD, PhD, is a management consultant in New Jersey, and co-founder of Harvard’s PASTEUR program in translational research. This essay originally appeared in abridged form in the Second Opinions Forum of the Washington Post.

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eVisitJC Peirodyck dewidjohnsonJim Bertsch Recent comment authors
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JC Peiro
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JC Peiro

I know what Motorola did, and now just see where Motorloa and Six Sigma is.

dyck dewid
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dyck dewid

Insurance is the fox guarding the hen house. Take insurance out of my healthcare decisions. They interfere. They don’t reduce cost at all. They cause a lot of bickering about what they should and don’t cover. Paperwork is horrendous. It’s a mess hardly any lay person understands and it ends up costing us all more. How can we expect someone (Insurance) to cut costs that they are creating by their existence and for which they stand to gain? This is just stupid. (I know they employ a lot of people who would lose their jobs, and that would need attention,… Read more »

johnson
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johnson

1) How much is this IT gonna cost everybody and who is gonna pay for it?. More government grants? I doubt that with the state of our financial status. It seems everywhere I read IT is needed to deliver better healthcare. Technology isnt cheap and with all the new changes it looks like the one big winner here is gonna be the IT sector. No wonder its being pushed so hard. 2) There is not a whole lot of EBM out there. The EBM that does exist is good and should be followed. But there a lot of gray areas,… Read more »

Jim Bertsch
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Jim Bertsch

The human body is too complex in its inner workings for one person to understand it completely. The doctor must rely on his experience to make a best guess (diagnosis). Two Different doctors with different backgrounds can have wide variation in diagnoses and treatments based on experience. If either doctor used the others method of treatment, it would have less chance of success because he lacks the prerequisite experience. Guidelines are useful and well documented methods of treatment can improve quality of care. IT can help by organizing and presenting more useful information to a doctor so that he can… Read more »

Peter
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Peter

jd’s example of assemply line decision making must take into account why modern manufacturing is so efficient; it’s because of Industrial Engineers (http://en.wikipedia.org/wiki/Industrial_engineering)constantly assessing processes and applying their training, observations and real life application to an already controlled environment. I don’t know if their is a branch of medicine equal to an Industrial Engineer and if hosptials now have some system of similar evaluation and process application to give us intellengent treatment consistency. I don’t want a doctor to be a robot of assembly line mentallity, but I do want a doc that is an intelligent problem solver. Mark, I… Read more »

MD as HELL
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MD as HELL

Mark,
Excellant post. The worried well are whom we spend a lot of money on and who themselves spend a lot of money on health care. All this of course because we can’t just tell them they are well and be done with it. We have to show it; not just once, but over and over again, whenever their anxiety reaches fever itch.
The doctor of today will not exist in ObamaCare. The doctor of tomorrow is not going to go to medical school to be a “provider”.

Mark
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Mark

POOKIEMD: is right on the issue, well said! Dale Halling: agree completely Margalit: I again agree with you, There are several very big problems with this protocol line of thinking. There seems to be a belief that physician aren’t practicing most efficiently or safely if a guideline isn’t followed, that they require some motivator to make the best decisions. This shows a total misunderstanding of how and why people get well and why physicians do a job that no studies will ever approximate. We must not forget that physicians are good at their job because we select for intelligent, complex… Read more »

docanon
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docanon

David, excellent post. JD is right on the money…your analysis is much more intelligent than the typical argument usually made by the growing anti-quality measurement movement (Dr. Jerome Groopman is probably the worst and most cynical of the lot). The central problem here is that for the vast majority of medical scenarios, we just don’t have scientific evidence to guide us. My medical education socialized me to believe that a reductionist understanding of biology would provide me with a scientific basis for treating disease, but my residency and fellowship proved just how misleading this mindset is. After all, how many… Read more »

Dr. Pandey
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Physicians do not innovate. That is not to say that some have not done. Have you ever talked to one..they will quote and research, and statistics. I am not sure if it is training issue or competence…but it is what i have observed. Healthcare innovations are away from clinics most of the time. I once had the urge to work on cancer research – I have always beleived that the solution to cancer is not as difficult as people have made it out to be and wanted to prove. I even negotiated with John Hopkins to give me a platform….and… Read more »

spike
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spike

What I don’t understand is what would make a doctor feel like it’s ok to go against established science when treating a patient. It seems like doctors often think back to something that’s worked in the past, which is susceptible to anecdote effects that aren’t based on actual data. I understand there is a lot of gray in medicine, but I also understand there’s a lot of black and white. I’ve never heard someone complain about any of the measures CMS has issued for hospitals on AMI, pneumonia, etc., it seems like those are pretty well-established, and yet many hospitals… Read more »

eVisit
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Some people just ignore facts.

Mimi Saffer
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Mimi Saffer

There are excellent examples working right now in real healthcare settings of approaches that address all of these concerns. These programs are simultaneously reducing unnecessary variability in care, preventing harm, improving patient outcomes, testing innovations, AND systematically identifying new standards of care where no standard or guideline currently exists. Guidelines alone — no matter how strong the evidence base — cannot accomplish this. Improvement science, which addresses both standardization and innovation, can accomplish this. I’m most familiar with pediatric examples, all of which are national networks of clinicians collaboratively implementing systematic improvement programs and making remarkable progress: 61 pediatric intensive… Read more »

Curtis Rooney
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I agree with David that there is a critical need to ensure our health care system balances the provision of consistent medical care (some would call ‘quality’) with the inclusion of innovative products and services. The ideal process, to better ensure this goal is met, is for doctors, practitioners, researchers and administrators to have a ‘whole-of-system’ perspective. This is defined as a comprehensive 360 degree view of existing medical practices and devices, hospital care developments and over-the-horizon products and services. The Health Care Group Purchasing Organizations, or GPOs provide our heath care system with this type of information and ‘creative… Read more »

Dale B. Halling
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Compulsory standards inherently limit innovation, by freezing the art at a point in time and abdicating a physician’s and patient’s judgment for a panel of experts. When confronted with this standardized treatment as a patient, I am unimpressed with my physician, who do not seem to be able to think for themselves. I also suspect that the panel of experts is less interested in my health than their own agenda. The reason why the US has the most advanced medical treatments in the world is because of innovation. President Obama’s proposals would exacerbate medicine by standards, for more information see… Read more »

RW
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RW

We have to find a balance between “trust me – I’m a doctor” and rigid guidelines that punish physician’s for showing good clinical judgement. A focus on outcomes more than process is one way to do this. A focus on assessing care for populations is another, including assessing “system” performance instead of just individual performance. Fundamentally though, physicians must step up and lead these efforts, instead of sitting on the sidelines and complaining about standards pushed upon them.

jd
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jd

Don’t get hung up on the word “implementer.” I just used it as a placeholder. As I said, the front-line practicing physician basically does this right now, just in a less systematic way. You already are seeing an “implementer” most likely.