Innovation: Curious Word

you follow the health IT media, you cannot escape the new and
obligatory word, Innovation. Every self-respecting article, blog post,
press release or casual comment on line is not complete unless some
reference is made to Innovation, its derivatives (innovators,
innovative, etc.) or compounds (foster innovation, disruptive
innovation, etc.). By now I am ready to add Innovation to the infamous
Do Not Use category, along with Synergy, Turn-Key and One-Stop-Shop, to
name a few.

According to Merriam Webster Dictionary Innovation means the introduction of something new or a new idea, method, or device. That’s probably a bit too vague for us. The Business Dictionary has a more interesting definition of Innovation: Process by which an idea or invention is translated into a good or service for which people will pay.
Since Health IT is a business, this definition makes more sense. It
turns out that there are various types of Innovation. From a user point
of view there is Evolutionary Innovation, which requires very little
learning from the end user and not much change to routine, and there is
Revolutionary Innovation which completely disrupts routine and requires
learning new ways of doing things.

So are we Evolutionary or Revolutionary in Health IT? If you ask
physicians, they will probably say that EHR is revolutionary, since it
forces them to change their workflow and the learning curve is very
steep. If, on the other hand, you take a step back, it is clear that
workflow hasn’t changed much. Patients still make appointments, show up
at the front desk, wait in waiting rooms, have nurses bring them to the
exam room, vitals are taken, doctor steps in and out and it all ends
with a claim to the insurance company. The only change is that paper
has been replaced by a computer, and computers are ubiquitous in
everyday life. All the talk about workflow redesign boils down to minor
simplifications due to the fact that the chart is available to all
simultaneously. EHRs are only incremental evolutionary innovations.

Well then, maybe we need a more Revolutionary Innovation, one for which
doctors will be willing to pay. This is definitely the prescription
from new entrants, or hopeful entrants, to the EHR market: the legacy
EHR incumbents have failed and we need a slew of low priced new
products, preferably fragmented into sub products, so that physicians
can pick and choose from an ever increasing array of choices. We
currently have several hundred EHRs to choose from. Maybe if we had
several thousand modular choices, every doctor will be able to find a
combination that fits his specific needs. It’s all about choices, or is
it? There are numerous studies
showing that over a certain threshold, more choices only slow down
purchase rates and actually make shoppers disenchanted with their
purchase. Maybe if we had just a handful of EHRs, things would be
different. Maybe too much of this type of innovation is detrimental to
an industry as a whole.

More recently our hopes have turned to Democratizing Innovation
and hoping that Innovation will come from consumers armed with medical
records. It is very likely that a healthy crop of consumer applications
will be created to analyze all those medical records, provide advice,
second opinions and even therapies outside the established medical
settings. Some will be good and some will be harmful. Caveat emptor, as
always, will be the rule and we still need to find out if this idea can
be translated into a good or service for which people will pay. Yes, pay, either by hard cash or by bartering their private information for services.

To judge by current developments in Health IT, we will be witnessing
both Revolutionary Innovations mentioned above, in a few short years.
Will they revolutionize Medicine and Health Care? Not very likely. The
most likely revolution will come from administrative simplifications,
payment reform, creation of Medical Homes, education, medical research
and eventually, technology inventions similar in magnitude to the
silicon chip. To be sure, Health IT has a major role in all these
upcoming changes, and Health IT will have to incrementally create a
standardized Clinical Information Highway on the Internet to support
change and improvement, but we will not be revolutionizing health care,
anymore than desktop publishing has revolutionized literature or
financial IT has revolutionized Wall Street.

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6 replies »

  1. Margalit, what I mean by “easy to use” is not “some new concept never before seen in software.” We can do wonderful things with what we have if we try.
    What I mean is a system that simplifies the process of assembling and generating patient information so docs can easily enter, access, retrieve and manage their patients’ medical information.
    To accomplish this, developers first must understand their objective. It is to meet the needs of the user — so they must adopt the perspective of the user, not the developer.
    Once the objective is clear, implementation becomes clear, too. It isn’t rocket science. It is doing simple things like using check boxes to enter data, auto-populating data fields, creating summary reports from data within the system, displaying screens in logical sequence, minimizing the number of clicks to drill down to basic records, etc.

  2. Merle, Hilary was my biggest disappointment after Al Gore. Oh well, I need to get over that…. 🙂
    As to EMRs, I agree with almost everything you wrote. The only problem I have is in the definition of “easy to use”. What does it mean? Is it some new concept never before seen in software? I think it might be, but if it’s not, then it will be only incrementally better than what is out there today. Maybe like the difference between salesforce.com and, say, SAP. It’s not a revolution or a major disruption.
    If you talk to doctors, you see that they just don’t want to be bothered with data entry. This is the biggest barrier. Data entry interferes with their way of interacting with patients. This is where the pain is. If we could get the data to magically go into the computer, we’d have the mother of all disruptions. In my opinion we need a new way of interacting with computers that would obviate manual data entry. Whoever comes up with that will carry the day and not just in health care. I don’t know of anything like that out there. Maybe ONC should give someone a grant for this purpose.
    As to patients, I would love a health card like the French have with a chip that can access the data and I would like to see a standard format that all these EMRs can consume immediately and display right away. Your device is a big step in that direction and I think it is much more reasonable than an untethered PHR.
    I also like Patient Portals because they allow patients to communicate and perform transactions remotely, but I don’t really see this as truly disruptive either.
    If Ghandi was right, then I don’t know who to ignore or laugh at. I don’t see much out there as far as EMRs are concerned. Do you?

  3. Margalit, I appreciate your point of view but must disagree with you. The concept of disruptive innovation is far broader than you recognize. It applies to markets as diverse as manufacturing companies, schools, political campaigns and, yes, the world of healthcare IT.
    It has nothing to do with B2B, B2C or other such tactical issues. It involves disrupting an established “marketplace” by offering a different kind of product, one that meets needs currently unmet by established products or services. The techniques of disruption will differ by market but the results will be the same — the established market leaders will be left far behind if not put out of business.
    What are the unmet needs in healthcare IT? Not that data fields aren’t interoperable or that standards are lacking or that they all don’t use the same computer language. These clearly are problems but focusing attention on them misses the real issues.
    For 85% or so of docs and 70% of hospitals, the unmet need is a simple, easy-to-use, IT system that enables them to manage and exchange patient records so they can coordinate patient care and have the information they need to treat their patients — without ruining themselves financially.
    A second unmet healthcare IT need is to give patients copies of their actual medical records that they control, are secure and private, and available to their care providers whenever the patient requires care — so the patient knows his or her physician has their information and can threat them correctly.
    Do you know any legacy EMR system that meets or even comes close to meeting these needs? I don’t. But what do you think would happen if such a system were offered to docs and patients?
    I suspect physicians and patients would rapidly embrace it to the dismay of established vendors. I also suspect the established vendors would ignore this disruption because the new, simple system doesn’t begin to compare with their feature-laden systems. By the time they realize what has been happening, they will be too far behind to catch up.
    That’s what happened to disc drive manufacturers (that Christensen studied), American auto manufacturers and even Hilary Clinton in her campaign for the Democratic nomination.
    As Ghandi put it, though addressing a different disrupted market: First they ignore you. Then they laugh at you. Then they fight you. You win.

  4. Merle, I have the utmost respect for Prof. Christensen’s work, but I don’t think it is entirely applicable to our small part of the world.
    The common opinion regarding legacy EMRs is that they pack too much functionality, so it stands to reason that if we could come up with a stripped down version, it would be both cheaper and easier to use, much like the famed Southwest Airlines disruptive model.
    Southwest discovered that one type of airplane and removal of food service and seating reservations (amongst other things) were acceptable to customers.
    So what reductions would be acceptable to our customers? Let’s pick something obviously unrelated to getting records in electronic format, something like intra office messaging. I don’t know if you ever tried to sell an EMR to a doctor, but I can tell you that if you state upfront that you don’t do messaging, they will look elsewhere. This is true about a myriad of other seemingly unimportant features. Worse than that, there is a wide range of opinion as to what a “must have” really is. You would be hard pressed to find any consensus other than prices need to be lower.
    It turns out that our market of physicians, really a B2B, is very different than Southwest’s potential market of millions of pretty uniform consumers, B2C, both in size and purchase patterns.
    Southwest could afford to forgo the well heeled consumers that preferred first class accommodations. An EMR vendor’s market is at most a couple hundred thousand customers and for most vastly less. And on top of it all, ours are not recurring purchases. You cannot afford to discard any market share if you want to stay in business.
    So basically, with all the so called bloat, there isn’t enough extraneous utility in EMRs to shave a significant portion of it off and maintain interest of a large enough market share to stay financially viable.
    All that said, Southwest didn’t just cut frills from flight service. They also innovated things that were not visible to consumers. They drastically improved operations and secured cheap fuel prices. All this resulted in lower costs. They also created a web based reservations system that is still unrivaled by the competition.
    I think that’s what EMR vendors need to do. Find ways to manage costs of production, distribution and implementation down and drastically improve usability of their user interfaces.
    Simplistic little modules are just going to force docs to buy more “stuff” to achieve the same results. User friendly products that allow incremental learning and utilization will have a better chance to succeed, particularly if the costs mirror the level of utilization (disruptive pricing model).

  5. Margalit,
    You have defined innovation as “Evolutionary Innovation, which requires very little learning from the end user and not much change to routine, and. . . Revolutionary Innovation which completely disrupts routine and requires learning new ways of doing things.”
    I’m afraid these definitions lead you down the wrong path and to erroneous conclusions.
    I suggest you consider definitions used by Clay Christensen in his landmark book, Innovator’s Dilemma, namely, sustaining innovation and disruptive innovation.
    Sustaining Innovation relates to improving existing products by adding features. This type of innovation ultimately results in over-engineered, over-featured products that far exceed the needs of their customers.
    Disruptive Innovation relates to creating new products that meet a currently unmet need. Such products typically are simple, narrowly focused, cheap, and easy to use. They disrupt the established vendors and existing markets.
    Looked at through this Christensen prism, today’s legacy EMR systems are the result of many years of Sustaining Innovations, and far exceed the needs of their physician customers. They are too complex to install and learn, too cumbersome to use, far too expensive, and they are incompatible with one another. That’s why only 15% or 20% of our physicians have adopted them.
    In contrast, healthcare IT needs Disruptive Innovations. Simple easy to use systems that enable physicians to move from paper to electronic records easily, cheaply and with as little disruption as possible. In short, systems that provide what doctors need and want.
    My concern is that the path we are going down will entrench legacy systems and stifle development of systems that will disrupt today’s marketplace and give physicians what they need to improve outcomes and the quality of care, and reduce costs.