Healthcare is suffering from Innovation Constipation (IC). The signs and symptoms are everywhere with more appearing daily. The problem is particularly acute in healthcare IT (HIT). Despite enormous effort and investment, the healthcare industry struggles to prove ROI, drive out excess expense, align technology with strategy, enable tactical agility and create great consumer and end-user experiences. Too often, HIT solutions are neither intuitive nor work-flow friendly.
The diagnosis is particularly obvious when compared to progress in the rest of the digital economy. If you really want your eyes opened, talk to tech experts from other fields who have recently entered healthcare. They often shake their heads in wonder at some of our practices. Or, talk to patients. They get it. They live in the 21st century with an amazing array of apps and services designed to be user-friendly, effective and convenient. Except for healthcare.
What’s going on here? I’ve worked in healthcare for decades and I’ve concluded that the underlying mechanisms of IC rest on a combination of ineffective strategies, technologies and behaviors. The good news: there are home remedies for IC.
Moonshot Improvement Methods
A primary cause of IC is that healthcare organizations generally favor taking the Moonshot approach to improvement efforts. A moonshot consists of a large upfront investment in planning, followed by a big-bang implementation.
The risks and costs of failure are real and potentially very high. There’s a non-zero chance of zero ROI. Frequently, big-bang efforts fall short resulting in additional costs and an extended period of optimization. The original performance goals may never be reached and can be difficult to sustain.
Agile Change Methods
By contrast, rapid-cycle change (RCC) methods, based on the work of Edwards Deming and others, approach improvement through a series of small tests of change. Each small investment of effort leads to additive improvement over time.
Essentially, there is always an ROI and no possibility of failure since the point is to learn from each small experiment and iterate. RCC tends to involve smaller, more diverse teams. It’s difficult to do if you don’t include both experts and end-users. So, to some degree, change management is baked into the approach. The same cannot be said for moonshots.
In general, RCC approaches are the preferred method whenever possible and practical. Sometimes you have no choice and must risk a Moonshot, but remember, even the original US Moonshot broke the challenge down into stages by first achieving Earth orbit and then building upon that success.
Moonshot Approaches to Interoperability
Unfortunately, moonshot thinking is driving a lot of interoperability efforts right now. I know this view may not be popular, but there is significant risk in only pursuing consensus-based approaches like FHIR. Advocates of this single-threaded approach hold out a vision of a single standard. But, is it wise to bet the farm that one approach produced by a consensus group will succeed? If it fails, or falls short, the consequences for healthcare are enormous.
To be clear, I am not against FHIR as a concept. My concern, which is shared by others, is relying on FHIR as the only solution. If history is any guide, we won’t end up with a single, widely-acceptable solution, but rather one that favors a few incumbents and drags out the interoperability crisis even longer. Given that there are alternative approaches, why are we taking this risk?
As pointed out in a recent Medical Economics article, other industries pursue more open, market-based approaches that share many of the characteristics and benefits of RCC methods. They enable a variety of solutions to rapidly enter the marketplace and create choice. Some will fail, but not all. Competition and experience winnows the field to the best performance at the best price. The risk/reward ratio is substantially altered. These industries have two other RCC-like qualities. They use APIs and they adopt highly collaborative business relationships.
APIs are Agile, Everything Else is a Moonshot
APIs represent the Industrialization of Health IT, while traditional approaches—based on HL-7 and custom ETL—resemble pre-industrial, artisanal crafts. APIs are rapidly produced, deployed and modified in incremental fashion. They reflect, and are a consequence of, the shift to agile software development. It’s another example of moonshot vs. RCC approaches.
The benefits are impressive. Well-designed APIs are platform agnostic, reusable and highly scalable. They can be deployed as a package making the full suite available on-demand. Application developers who rely on APIs for integration are agile and can rapidly move a new concept from prototype to product. And, their products can be plug-and-play across disparate platforms. APIs are better, cheaper and faster in ways that traditional artisanal methods, by their very nature, can never be.
This goes far beyond simple records portability and has enormous implications for innovation. Look around you and marvel at the transformation of banking, telecom, retail, logistics and other sectors of the digital economy. API technology plays a huge role in interoperability both within and across these industries. They can do the same for healthcare.
Behavioral Causes of Innovation Constipation
We also see the RCC vs. Moonshot pattern when observing the behavior of different stakeholders such as vendors and health systems. As illustrated below, their business strategies are distributed across various points on a behavioral spectrum from collaboration (A) to control (E). Between points A and E lie a various combinations and intensities of these behaviors.
Point A on the curve represents organizations that invite disruption and embrace technologies like APIs. They purposefully pursue business models designed to succeed in a collaborative-competitive environment. Their goal is to grow the pie for many rather than fight over a slice. They see customers and competitors as partners rather than adversaries and seek to work with them where possible. They adopt this approach not only because it is sustainable, but because it produces superior financial results over time. This may seem counter-intuitive, but analyses like Firms of Endearment support this view. Measured over a decade, organizations like Toyota, Whole Foods and Southwest Airlines have achieved manifold the annual growth rate of their more traditional, control-oriented competitors.
Point E, at the other end of this spectrum, denotes those who adopt controlling behaviors. Their business model is based on fighting over slices rather than growing a bigger pie. They leverage market dominance to erect administrative and technical barriers that inhibit competition and cause data-blocking. They hand pick a few selected partners rather than enabling a wide range of participants to create win-win solutions. Some engage in rent-seeking forcing weaker players into highly-asymmetric business agreements. Others try to inhibit discussion and dissemination of information through excessive gag clauses and confidentiality agreements.
This business model may seem tough and smart. It is neither. Eventually, they find themselves struggling to maintain revenue. It becomes increasingly obvious to everyone they cannot innovate quickly or broadly enough to meet their customer’s needs. The gap between their performance and that of the Firms of Endearment group grows wider with each passing year.
The same argument holds true for activities like data-blocking that inhibit collaboration and the flow of data. If you believe owning the data in healthcare is a competitive advantage you are mistaken. Ownership is only a short-term advantage which will inevitably fade due to external pressures like reporting requirements, value-based care, consumerism and transparency. The long-term advantage is in agility, actionable information and high-reliability, not in data hoarding.
If you need a real-world example, this recent interview of CIOs from California offers a lot of insight. Clearly healthcare and HIT need more of this kind of collaboration and the RCC-like agility it can bring. Otherwise, controlling behaviors will continue to drive us towards moonshots that can harm the industry, and ultimately (and ironically) hurt the control-oriented organizations themselves.
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.