Medicine has made great strides over the last 50 years. Modern medicine looks a lot different than the medicine of 1966. Today providers are 3d printing bones, replacing organs, and conducting minimally invasive surgery.
Yet healthcare operations of 2016 are remarkably similar to healthcare operations of 1966. Why haven’t the delivery systems of healthcare changed? Why haven’t core provider operations changed much in the last 50 years, and why do providers struggle to adopt health IT even though they’ve adopted so many medical innovations?
The Innovation Has Been In The Tech, Not The Process
In short, because it’s much easier to adopt new medical treatments than to adjust the operations of a healthcare delivery system. The former is an incremental improvement. The latter requires business model changes, changing job roles, and more.
The R&D burden for the vast majority of medical innovation is extremely high. Achieving FDA clearance is incredibly difficult and expensive: tens of millions of dollars, and in the case of pharmaceuticals, hundreds of millions.
But once a new pill, cream, device, test, or treatment has been invented, the healthcare system can “adopt” it pretty easily. All of the existing infrastructure is in place — pharmacies, labs, ORs, physicians, surgeons, etc. A few examples:
The only cost to healthcare providers to prescribe a new pill is educating the physicians. Physicians are mandated to earn Continuing Medical Education (CME) credits, and many are active in their respective specialty-specific communities. Pharmaceutical companies know this and market to physicians through these channels. Once a physician has learned about a new treatment and is convinced of its clinical benefit, her organization — a solo practice or hospital — doesn’t need to do anything else in order to prescribe the new medication to the patient. The physician prescribes the treatment, and the patient will receive a prescription and a nearby pharmacy will dispense the pills. This process happens identically if the treatment is brand new or if it’s penicillin. The medication prescription process is remarkably unchanged in the last 50 years. Even moving from paper to e-prescribing hasn’t really changed the workflow around prescriptions. The pharma company will work with medical distributors like McKesson to ensure the treatment makes its way to pharmacies in every geography. Providers don’t need to worry about where the pill came from or how it got there.
Similarly, the only cost to a healthcare organization to adopt a new piece of lab equipment is the cost of the equipment itself. A hospital already has an ASCP-certified lab (the ASCP certifies labs for quality and safety standards), lab technicians, etc. The only additional costs to the hospital of adopting a new medical diagnostic tool is the device itself, and few hours of training per lab technician. The hospital doesn’t need to build any new physical or virtual infrastructure, or define new processes. Once the new device has arrived, physicians are educated, and can then place orders that will utilize that machine. The process change required is minimal.
A significant majority of medical innovations are “black boxes.” Physicians don’t need to understand every chemical reaction that will occur in the body after a pill is taken. The pill is effectively magic — the patient consumes it and gets better. The same is true of the latest diagnostic tools. Put the blood in, get an answer out.
There are certain medical innovations that require some operational changes. For example, let’s examine robotic surgery. Surgical robots are a “black box” like other physical devices — surgeons don’t need to understand the control systems in the robot that guarantee millimeter precision. But surgeons and surgical staff need to be trained and certified to conduct robotic surgery. The training program for daVinci, the leading surgical robot, typically takes a few months to complete. However, surgical robots don’t change the operational processes around surgery. Patients are still referred to surgeons by more general physicians, surgeons still consult patients before surgery, patients still come to the hospital, staff still prep and sterilize the OR, the patient is still anesthetized, and the patient is still prescribed bedrest, antibiotics, and perhaps other medications afterwards. Although the technical implementation of surgery is vastly different, the broader process around surgery hasn’t really changed.
Health IT Requires Material Process Change
Health IT innovations couldn’t be more different than medical innovations. Health IT solutions by definition are not medicine. Health IT solutions do not directly impact the health of the patient at all, even if the patient logs in and uses an app. No It solution will magically make a patient better, and no IT solution will diagnose. Medical diagnostics and treatments require chemistry. IT is not chemistry.
It’s important to note that all health IT solutions require some level of organizational workflow change. The change may be relatively trivial, but a workflow change is required. Many of the greatest opportunities to improve outcomes and reduce cost to be gained from adopting health IT require massive organizational changes. Omada Health is a great example of a radically different diabetes management service. In fact, Omada’s technology and service is so unique that the company chose not to sell the software to existing providers, but to act as providers themselves and contract directly with self-insured employers, payors, and in some cases, at-risk providers. Omada determined that their clinical service would be more effective if they built it themselves, rather than helping hundreds of organizations modify their existing operations. Their success indicates that this was probably the right decision.
Information technology can do four fundamental things: collect, process, store, and share information. IT will never do anything more. When a provider organization adopts a novel health IT solution, there is an implicit acknowledgement that the organization was organized sub-optimally. When an organization adopts a novel piece of health IT software, the organization needs to rethink existing workflows and processes. Let’s use Patient IO as an example.
First, a quick primer on Patient IO. Patient IO is a cloud based care management platform that’s sold to large healthcare provider organizations. When hospitals discharge a patient after surgery, the discharge nurse typically provides the patient a few one-pagers that inform the patient on dietary restrictions, medication requirements, how to gradually get back into sports and athletics, etc. The patient is left to manage the entire post-discharge process herself. Using Patient IO, providers prescribe patients the app. The app sends regular reminders to patients using push notifications. For example, if the patient is supposed to walk .5 mile per day for the first week, then 1 mile a day for the 2nd week, the app will track activity on the user’s smartphone, and send the patient reminders throughout the day to increase activity. That data is reported back to the provider, and providers follow up with patients and their families as necessary to encourage activity. The same concept can be applied broadly for any care plan for any disease or procedure.
Adopting Patient IO is a big change for provider organizations. Previously, the organization may have staffed a few people to call patients and follow up after surgery. If the patient answered the phone, the caller may have asked a few questions about physical activity. The patient may have lied about the truth out of embarrassment. With Patient IO, nurses engage with dynamic dashboards based on hard data. These dashboards show compliance of patients based on time (eg all patients seen last week), by disease state (eg all diabetes patients), procedure (eg all patients who had knee replacement), and other factors that the nurse determines to be useful. The nurse then engages non-compliant patients with much greater rigor than the organization otherwise would have since the organization can devote energy and effort to help the patients most in need.
Patient IO is just an information arbitrage tool. Previously, healthcare organizations had no ability to track or understand this data. Now they do. As a result, it’s logical for them to rethink how they care for patients using this new tool. The tool itself does not make the patient better. Instead, the tool helps patients take better care of themselves, and helps providers engage with patients who are struggling with compliance.
Building Patient IO’s tech required 1/100th the financial resources that it took to develop a drug, but requires 1000x the organizational change. The same is true for most IT solutions. They are orders of magnitude more capitally efficient than traditional medtech, but require huge organizational changes to reap the benefits.
Over the last 50 years, providers haven’t developed the organizational capability to change their fundamental processes. They simply didn’t have a reason to. Although medicine was advancing rapidly, the advancement was literally contained to just the medicine. No one other than the vendor and the FDA really needed to understand the inner workings of the black boxes that were being invented. Healthcare delivery broadly remained unchanged until recently. Information technology is breaking old assumptions in healthcare delivery processes. This, coupled with the rapid succession of government mandates (meaningful use, ICD 10, managing lives at-risk, etc), has strained healthcare delivery systems. They are still learning how to adopt technology at the pace at which technology moves.
The future is incredibly exciting. As processes and medicine evolve together, we will be able to achieve results that were never before possible.