Years ago, I read an article in Smithsonian Magazine about Dr. Yoshiro Nakamatsu, a.k.a. "Sir Dr. NakaMats," who claimed to have more than 3,300 patents—including the original floppy disk. He had some interesting things to say about successful innovation:
That early floppy, he says, is perhaps the purest embodiment of Ikispiration, the Dr. NakaMats system of creativity. It has three essential elements: suji (“theory”), pika (“inspiration”) and iki (“practicality”). “To be a successful invention, all three are needed,” says Dr. NakaMats. “Many inventors have pika, but not the iki to realize their dreams.”
I was reminded of Ikispiration recently when Apple rolled out a patient-facing personal health application and Amazon, JP Morgan Chase and Berkshire Hathaway announced they were launching a new company to innovate healthcare:
"The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost."
These announcements have garnered a lot of attention and a mix of enthusiasm and skepticism. One well-seasoned healthcare IT colleague responded to the above quote with a sarcastic, “Gee, why didn’t we think of that!” Echoing a famous healthcare newbie, another said, “Who knew healthcare was so complicated?” and then added, “Pretty much everyone who has worked in healthcare or dealt with serious illness!”
Decades of experience have taught me that we must seek ideas from outside healthcare if we are serious about transformation. There is a lot to learn about efficiency, safety, quality and satisfaction from other industries. There is also much to gain by studying marketing, behavioral economics, human factors design, organizational culture and many other fields. So, I strive (and sometimes fail) to be an open-minded skeptic, to maintain equipoise between unbridled enthusiasm and rank cynicism.
However, it’s not a biased conceit to say that healthcare really is different from other industries. That’s because healthcare is:
- Very personal and touches much that is sacred about us as human beings. Patients are not exactly like consumers, but they are more alike than we have previously recognized.
- Pervasive and spans the continuum of care from home to school to work and everything in between.
- Very simple or exceedingly complex or both.
- Diverse, encompassing everything from wellness and prevention to chronic disease to palliative care and hospice.
- Mostly focused on “sick care” and only deals with a small part of what actually drives health outcomes.
- Culturally complex and highly stratified with distinct tribes and clans who must collaborate and have different knowledge, power, biases and motivations.
- Hobbled by economic and business models that don’t align well and affect 1/5 of U.S. GDP.
- Highly regulated.
For all these reasons, Ikispiration makes me skeptical about these new entrants in the race to fix healthcare. They are likely long on pika (“inspiration”), short on suji (“theory”) and shorter still on iki (“practicality”). It’s a pattern I see all the time. A very cool, even inspired idea is put forth, but those suggesting it don’t know much about the theory that drives healthcare delivery and reimbursement. Frequently, they lack meaningful practical knowledge of how things actually work in healthcare (as opposed to the theory) and how to effect change in culturally complex environments.
They also tend to overlook the iron triad of “people, process and technology” that determines the success of most improvement efforts in healthcare. Deploying technology solutions is pretty worthless if you don’t address underlying processes (typically workflow) and people’s needs, motivations and culture through substantial change management efforts.
Consider Apple’s new personal health app. It “checks the boxes” on inspiration and theory. A mobile personal health record (PHR) could be a big win. Apple’s ability to deploy simple, elegant solutions could make it a formidable competitor in this arena. But dig a bit deeper and you will find that the data exchange is limited and hangs by a single, narrow thread: FHIR (Fast Healthcare Interoperability Resources). Sorry, but that’s only practical for getting a very limited subset of data out of EMRs (electronic medical records). Worse yet, FHIR implementations vary from EMR vendor-to-vendor compromising its ability to be a consistent standard.
This reminds me of the early days of personal finance programs that only let you download transactions for a few banks and none for credit cards. Only the most obsessed users were willing to do all that data entry. Personal finance took off when banking achieved meaningful interoperability. PHRs will be the same.
In short, Apple may design a “killer app” but still faces the same interoperability problem as any innovator in healthcare. Google and Microsoft faced the same challenges in their PHR efforts, which they ultimately abandoned. In each case, these companies had pika and suju, but not iki! As I have written before, the “iki solution” for interoperability will be robust APIs (application program interfaces).
What awaits Jeff Bezos, Warren Buffet and Jamie Diamond on their most excellent adventure to introduce transformative technology to healthcare? Recently, I was working on a project to leverage real-time EMR integration for patient satisfaction surveys. There was plenty of pika and suju in those discussions as we explored theories and ideas about detecting and heading off or remediating negative patient experiences. Excitement grew as we discussed how automating the administration of these surveys could reduce the cost while improving the yield and accuracy and would position healthcare providers to respond in a timelier fashion.
Then we ran smack into the iki of Centers for Medicare and Medicaid Services (CMS) regulatory requirements. There may be many good reasons to survey patient satisfaction, but the most compelling for a health system is the impact the CMS HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey has on reimbursement. CMS places significant restrictions on when and how these surveys are administered. As we experienced firsthand, this iki significantly complicates efforts to innovate and automate.
So, let’s welcome Apple, Amazon, JP Morgan Chase and Berkshire Hathaway and all they can bring to improve healthcare. We definitely need their help and that of many others, because real transformation can only result from a synthesis of old and new. Both old-timers and newcomers alike should strive to be open-minded skeptics and engage constructively in this opportunity to learn together. We would also be wise to remember Dr. NakaMats and his prescription for successful innovation: Ikispiration.
Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email DaveLevinMD@gmail.com.