At the 20-plus-hospital UPMC health system, a massive integrated health system that encompasses more than 1,000 care locations and more than 60,000 employees, things are moving forward in numerous areas. One particularly interesting arena is that of the tech development test bed that is UPMC Enterprises. Here’s how the leaders of UPMC Enterprises explain what this business division is all about: “UPMC Enterprises believes that the smart integration of technology within the health care industry is an opportunity to both improve the quality and lower the cost of health care. As a leading integrated delivery and finance system (IDFS),” the organization’s website notes, “we harness the strength of our clinical, technical, business, and capital resources to develop, test, and deploy health care products and services that improve the lives of patients across the globe and reduce costs.” And there is a clear rationale for this development work, leaders note. “With more than 20 hospitals and a 2.5 million-member insurance company, UPMC understands the importance of both providing care and paying for care,” UPMC Enterprises’ website notes. “UPMC works to maintain the health of its insurance company members, while also caring for patients in a variety of circumstances.”
One of the many clinicians involved in development work at UPMC Enterprises is Shivdev (Shiv) Rao, M.D. Dr. Rao, who is director of clinical innovation strategy at UPMC Enterprises, still sees patients 20 percent of his time each week, and is a faculty member in the Cardiology Department at the health system’s Heart and Vascular Institute.
Recently, Dr. Rao sat down with HCI Editor-in-Chief Mark Hagland, in the development offices of the organization, in the Bakery Square neighborhood of Pittsburgh, to talk about what’s going on at UPMC Enterprises, and his role in its activities. Below are excerpts from that interview.
Tell me a little bit about how UPMC Enterprises is organized?
We organize ourselves here into four domains. One is infrastructure-oriented; the others are our payer, provider, and consumer domains. And we collaborate across all four. There’s a small cohort of doctors who embed themselves here and spend a significant amount of their time here. I spend the most time here, 80 percent of my time; and then 20 percent in patient care. I went to medical school here at the University of Pittsburgh, and then, I was at the University of Michigan for my residency. And it seemed to me at the time that there was a limited number of professional routes to take—the clinical investigator route, the clinical scientist route, the clinical educator route, and the clinical administrator route—those were the paths I saw in front of me. But I never saw a clinical innovator route. And as overused as the term innovation is, that is what excited me.
Shivdev Rao, M.D.
My clinical interests are around patient safety and disease prevention. But I also have interests around research and technology. And I love to explore and connect the dots around all of those realms. And here at UPMC Enterprises, we have a broad scope. At various times, it feels like we’re a venture fund, an innovation shop, or a tech accelerator. But what that gives me the opportunity to do is to grow across all those different skill sets. And that offers people like me, physician innovators, opportunities to grow. And it’s the payer-provider piece that differentiates everything we do here. It goes well beyond the traditional clinician lens.
How do you see the role of physician innovators like yourself, in the context of the way in which medicine has historically been practiced? You’re really expanding the scope of what physicians with medical training can do to impact patient care delivery, on rather a broad scale.
Yes. The thing that distinguishes UPMC Enterprises is our ability to have doctors, patients, and people from the health plan embedded in our activities, to make sure that our innovations “fit.” And that’s a loaded word. To me, that means that the innovations that we invest in and build need to sell themselves, so that their adoption does not involve additional overhead for providers. We try to work backwards from a vision of what we think a highly aligned, patient- and consumer-centric, future-looking patient care system looks like, and we try to invest in existing companies that are moving in that direction. But where we see green space, we’ll build it ourselves.
For example, a little app I’m looking at right now on my smartphone, tells me when any one of my patients is in the emergency department, is admitted as an inpatient, or is discharged. Where did this idea come from? Well, historically, what would happen to me is that I’d end up in clinic and see ten patients who’d already been in the hospital, and had had their cardiac meds had been changed without informing me. On the surface, this appears to be a very simple application, but behind the scenes, making it successful requires connecting a lot of dots between our inpatient system, our outpatient system, and our ADT system, pulling demographic data on these patients; and it requires pulling a care team together around these patients. So I now get actionable notifications. I can choose to call the ED, the patient, or any other doctors on the team.
It will tell you the change of medication lists that a patient is now on, once that patient has had an ED visit, been admitted, or been discharged?
Yes. As she walks into the ER, I get an immediate notification that Mrs. Smith is in the ER. And if it’s for chest pain, I’ll call her, or if she’s in the hospital, I’ll go see her. And I can tell you, when I show up, I look really good to hear. It’s called Augr Health, and it’s a project right now.
You’re essentially piloting it, then, with physicians, here at Enterprises?
Yes; but it’s not just for providers; it’s for care managers., too We have every care manager in our health plan using the app, and we have clinicians across the heart failure and inflammatory bowel disease areas, using the app. It’s in the hundreds of providers so far. We’ve surfaced something like 9,000 or 10,000 notifications, over the past several months. We’re following a really lean, agile process in developing apps and solutions like this, building very small prototypes, with a few people, figuring things out, do providers like this? If we have to put any effort into selling and pushing products onto our providers or patients, then it’s the wrong thing.
When did this particular project begin?
About eight months ago.
What was the team like that built this?
The team has two buckets. One is the actual product team that’s building and learning and putting it all together. The other team is the secret sauce here. It is the UPMC team—care managers, doctors, nurse practitioners, and social workers, who use the app. There’s a lot of amazing startups out there, but one of the challenges that these startups face is that the barriers to entry are really high; they can’t get access to the clinicians while they’re developing. The name of the game in tech is a really tight feedback cycle: you want access to certain people for feedback, while you’re developing any kind of technological solution. And that’s what we have here.
The development process must be fascinating for you as a practicing physician, correct?
Yes, it’s fascinating, and it’s really fun. And there’s this idea that’s starting to infiltrate medical training, and it’s borrowed from other industries—this idea of nurturing and creating interdisciplinary thinkers. Having depth in one area, but also being able to cross that depth with another area of expertise--for example, depth in healthcare plus some background in engineering. What I’m really excited to do is to bring in more of those types of doctors into the fold here at Enterprises, to help us build products and help us interface with those super-deep scientists in the hospital, as well as our own designers and engineers.
This seems like a smarter way to develop technology for care delivery purposes, in light of the f to the fact that electronic health records were built for somewhat different purposes from some for which they’re now being used, and therefore ending up being so clumsy in their architecture and workflow, correct?
Yes. We had to learn and get better. And things are getting better. They had to evolve. To your point, the opportunity we have here at UPMC, with that really tight feedback cycle, we have the opportunity to accelerate that evolution of healthcare technology. It’s already going to move …
What should the world of tools for specialists look, in five years from now, in your view?
It’s not a sexy answer, because the tech isn’t mature enough to be sexy yet. But here it is: in technology, we say that value “moves up the stack.” We have a stack of technologies, with foundational infrastructure, then middleware above that, and then you might get to the level of the actual user experience, including apps. And we’ve fast-forwarded in healthcare, when the foundation hasn’t been solid enough. We end up building unscalable products, products that might work for small cohorts, but that don’t work on a bigger scale, because the foundation is shaky. The industry is trying to work on the foundation, and we’ll get exponentially better when we create a better foundation, but it has to start from the bottom.
What do you think about the opportunity that has come with the FHIR [the Fast Healthcare Interoperability Resources] standard, in terms of changing the landscape so that apps and other solutions can really become interoperable and be made to connect with each other as needed?
The issue with those really cool apps is that they exist, but they can’t scale, and aren’t easily deployed. I think the movement around standards is fantastic and is required. But we are challenging ourselves at Enterprises to look at the whole data system, because there’s a lot more data besides EHR data; there’s socioeconomic data, payer data, genomic data, consumer data. And if we get too focused on just the clinical data, we’ll be doing ourselves and the patients a disservice. Because to create a complete phenotype of a patient requires input from many sources. So I agree about standards. I think the real challenge will be connecting the dots between all the data.
What do you think the next couple of years will look like here at UPMC Enterprises?
I think that Enterprises is going to continue on its current arc; we’re going to continue to strategically invest in forward-thinking companies that have a ton of potential, and we’ll look to accelerate those companies and put our muscle behind those companies. And beyond the investment lens, we’ll continue to build things that need to exist and don’t yet.
More broadly, what do you see happening in the industry around app development in the next few years?
I think organically, across the health system, everybody is doing their part in getting us to where we need to be, from a technology standpoint, and put not just the patient, but also the person, together. We’ll see a lot more companies exposing data, leveraging open APIs [application program interfaces], and building new things that we could never have imagined. I think that’s going to be the key for any real innovation.