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Checklists – the latest fad to hit health care? March 16, 2010

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I have a copy of Atul Gawande’s book “The Checklist Manifesto: How to Get Things Right“. It’s next on my reading list once I’m finished with Clayton Christensen’s book “The Innovator’s Prescription: A Disruptive Solution for Health Care“. Since I haven’t yet read Gawande’s book, I am not going to talk about the comment. However, I think it is safe to say that “checklists” will be the next big thing in health care for the next little while. Why do I think so?

The main reason is because the mainstream media seems to be picking-up on this idea that checklists will improve care and outcomes and have started writing about it.

Again, without having read the book, I can see how use of a checklist can help bring order to a complex environment. That’s always been the reason for use within the airplane cockpit. Some evidence on the impact of checklists is available from the AMA (Infection rates drop as Michigan hospitals turn to checklists) and the original NEJM article titled “An intervention to decrease catheter-related bloodstream infections in the ICU“

I’m hoping that checklists, even if they are a fad, do make a difference and improve care. If some of the needless complexity can be simplified with the knowledge codified (and thus more accessible), then this will be a great thing. Perhaps checklists will be a first step in making health care more open to disruption. Christensen’s theory points to the notion that codification of “expert knowledge” is a first step in making a process open to innovation and disruption. I’m just hoping that checklists can improve care.

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Tips for unleashing innovation March 15, 2010

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Came across a very interesting article with a list of 10 tips to encourage and foster innovation. Here is the list of 10 practices:

  1. Let the learning lead
  2. Learn to see
  3. Design for today
  4. Think in pictures
  5. Capture intangible value
  6. Leverage the limitations
  7. Master creative tension
  8. Run the numbers
  9. Make kaizen mandatory
  10. Keep it lean

The author is Matthew E May, an innovation consultant, who has written a book titled In Pursuit of Elegance: Why the Best Ideas Have Something Missing . He also maintains a blog titled In pursuit of elegance.

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Has ehealth become toxic? February 24, 2010

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A recent article titled “The chopping block: Which way Infoway?” makes me wonder if the term ehealth has become toxic in Canada.

First, a little bit of context. The National Post has been publishing a series of articles/comments on potential things to cut in order to bring (federal) government spending under control. Canada Health Infoway (Infoway) was clearly a potential target for the newspaper.

Given the eHealth Ontario spending scandal resulted in resignations, firings, and nearly $1B in funds being spent, I can understand public suspicion over anything ehealth related, particularly if it is related to government spending. In a similar vein, when speaking to some folks, I mentioned how I was interested in ehealth research and asked “are you sure?”, obviously trying to distance themselves from the scandal.

I can understand how people might be wary of the term ehealth given some of the setbacks in terms of not really delivering on the hype and promises, but does this signal a lack of support for the work that needs to be done? Perhaps this is just one step in the evolution of the field where there will be no distinction in how information and services are delivered. A colleague of mine recently reminded me of a comment I made a while back: the term ehealth will cease to exist in a few years time. Much like the term “e-business” has disappeared from the vernacular, I am confident that ehealth will no longer be used. Use of electronic tools will become part of how things are done without the need to bring attention to it.

So, even if the term is a bit “toxic” within the Canadian context at the moment, perhaps it is just one step in the journey.

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Chronic conditions account for growth in health care spending February 22, 2010

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A recent article published in Health Affairs titled “Chronic conditions account for rise in Medicare spending from 1987 to 2006” points to the changing nature of health care in developed countries. What is particularly scary is the disjoint between what (North American) systems are designed to deliver versus what the needs are. While some may see this as a threat, I see this as evidence for an opportunity to transform the health care system.

Given that chronic conditions are an increasingly important aspect of health care needs, I can’t help but point out that more needs to be done to support informal caregivers. By “informal caregiver”, I mean the family members and friends who support patients and provide necessary services that the health care system cannot. Like I mentioned, these are exciting times, but there is a tremendous amount of work to be done.

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Quick thought – is health care getting too big? February 17, 2010

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A post on Roger Martin’s blog at Harvard Business Review titled “The Inauthentic Communities of the Modern Executive” has me wondering if health care has gotten “too big”. In the post, Martin describes senior management has become separated from its customers due to the sheer size and growth of the corporation. No longer having that personal connection, senior management is distanced from the individuals and communities it serves. Martin writes:

Executives could have a relatively intimate relationship with their customers, who were mainly located in their company’s home region or at least country. Employee bases were smaller and concentrated close to home, which tended to make executives a prominent force in their home cities. And their shareholders stayed on the register for a much longer period than they do today.

This structure had a number of beneficial effects for executives. It was easier to get to know customers, figure out how to serve them, and continuously improve a product or service. It was easier to get to know employees because there were fewer of them and they lived nearby. And since the home city was more important to the company and the executive typically had a network of friends outside the company in that city, the executive was less likely to have a schism between his corporate role and personal role relative to the city. That is to say, doing things to benefit the city made sense both corporately and personally. On top of that, shareholders were more likely to encourage or at least tolerate long-term planning rather than very short term results because they planned to be around for the long-term.

While not perfect, this structure enabled the executive to live a reasonably authentic life; the way he wanted to live personally was largely aligned with her corporate responsibilities. He wanted to make the customers — whom he was likely to know personally — happy. He wanted to support his employees’ well-being — employees who he and his family probably knew. He wanted to be a respected figure in the city, a city that was important to his company and his family. And he wanted to make his shareholders happy because he knew that they had placed a long-term bet behind his company. If he worked on all those aspects of his community, he could be successful and happy. And by serving customers and employees well, the corporation was likely to keep on prospering.

We’ve started to see this trend in health care over the past while. Arguments for “economies of scale” and efficiencies have resulted in large, multi-site hospital corporations emerging as the norm. These larger organizations then start the cycle of competing for people, resources, and mind-share resulting in a predictable “arms race” to become the most prestigious health care institution either through research or best care.

We have also seen the move toward regionalized models of care which are an attempt to move away from the centralized “command and control” model to something that can better respond to local needs. In Ontario, the Localized Health Integration Networks (LHINs) are supposed to serve in this capacity to “determine the health service priorities of our regions” but I wonder if we are simply adding another layer of administration to the system and making the system bigger without knowing it.

Martin concludes his post, describing the effect of professional managers:

In the intervening years, as corporations have ballooned in size, the community has become far more impersonal and distant. Customers and employees have become more dispersed and distant and the home city has become less central — even expendable, as Boeing’s abandonment of Seattle demonstrated. And perhaps most important, a company’s owners have become a group of distant professionals who trade their holdings at the click of a button. Many large shareholdings, in fact, aren’t even managed by people.

It was just as this process was taking place that the idea that shareholder value was a corporation’s principal objective function took hold, largely, I think, through the agency of business schools, whose dramatic rise coincided with the decline of the traditional business community. With the new creed came an army of professional proselytizers who have come to be the principal agents in the executive’s new community: Wall Street stock analysts who cooed with approval when shareholder value was put first and delivered spankings when it wasn’t; Wall Street investment bankers touting “value accretive merger and acquisition ideas”; strategy consultants providing approaches to slash costs and “enhance shareholder value”; and the financial press looking for a story.

I wonder if the influx of management professionals focusing on quality of services, efficiency, and value have in some way replicated what Martin talks about. Is this a good thing? I am not advocating that we abandon efficiency, effectiveness, quality, and patient safety. What I am wondering is if we are making our health care organizations too large and complicated such that the managers are so far removed that “patient care” is just a catch-phrase used flippantly, much like how many companies talk about “customer satisfaction”?

I will admit that I do not have any solutions or suggestions to this potential issue. There are benefits to be realized as an organization like a hospital increases in size – increased specialization and diversity of services is one glaring example. But, every time I walk outside of the mammoth buildings of the large hospital corporations, I can’t help but notice that the administrative corridors and buildings seem to be getting larger and larger with more opulent furnishings.

The question I wonder is – is there a better way? Is health care getting too big? If “yes”, what do we do about it?

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“Waiting for Godot” or why Apple’s rumoured tablet won’t transform health care today January 26, 2010

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In a little over 24 hours, the technology world will be dissecting the announcements made by Apple at its special event. While everyone is expecting a tablet computer that will upend … something, I’ve been trying to hold my expectations in check. In my reading, I was surprised to come across an article titled “The Healthcare System: An Apple Tablet’s Biggest Opportunity” from ReadWriteWeb that Apple’s tablet could “transform our care delivery system in a major way”. While I am hopeful for a great product from Apple, I am skeptical that any single product could transform health care right now.

Even though the author does present valid points about why a tablet could be a great catalyst for adoption of mobile technologies in health care, he seems to forget some significant structural issues that need to be addressed.

1. Data definitions
Much to everyone’s chagrin, there still remains considerable work on developing standard data definitions. For example, I worked on a small project to develop a data dictionary to allow organizations to share information about lab results. When we started looking at the issue, there were no standard definitions used by organizations (often even within the same organization). We had to strike a working group to collect an inventory of definitions and then try to reconcile and agree upon definitions – all before getting approval from the clinicians. As such, much work still needs to be done to standardize definitions and then work needs to be done to link the systems.

2. Access and integration
Once the data definition issue has been addressed, getting access to information and integrating the information from different sources is the next big structural barrier that needs to be overcome. While a tablet is a great way to have information accessible at the point of care, significant work is required to get the data to a point where it is understandable and meaningful. The current legislation surrounding health data privacy and security often prevents novel ways to use the information because people can’t get access to it as the penalties can be severe.

3. Workflow, workflow, workflow
As much as a new tablet would be great, any potential solution has to overcome the issue of workflow issues. Clinicians are generally hesitant to try a new solutions because it doesn’t impact how they work in meaningful ways. Yes, a tablet could go a long way in making information readily available, but that’s only when the foundational issues have been addressed. The other systems and business processes need to be redesigned.

I’m a bit proponent of changing and transforming health care. I’m also a big proponent of utilizing new technologies when appropriate, but we can’t forget some basic principles:

Finally, I think the author forgets that technology is not a panacea that will auto-magically solve all of the challenges clinicians face. A tablet that functions and looks like something on Star Trek would be both amazing and absolutely delightful. However, we are likely to be “waiting for Godot” for a while longer as health care is not yet ready for a magical tablet. Perhaps tomorrow…

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Disruptors of the decade – not the time for health care January 15, 2010

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A recent blog post by Scott Anthony reported the results of a poll he ran to identify the “disruptors of the decade”. The results weren’t that surprising in terms of naming the companies from the technology and “emerging” categories. What was surprising to me were the companies in the established non high-technology companies category: Wal-Mart, Verizon, Dow Corning, General Electric, Goldman Sachs (?!), and Ford.

My initial thoughts as I read this post was “what about health care?”. Then, Anthony ends the post with a prediction about where the next disruptive titans will be. One of the categories was “health care, education, or cleantech”. Anthony states that “these three industries are screaming for disruptive innovation, and the innovators that deliver the disruptive goods are well position to create massive success stories”.

Part of the challenge with health care is how regulated this field is. As pointed out in Chrstensen’s book “Seeing what’s next: Using theories of innovation to predict industry change“, disruptive innovation is more challenging to take root in industries with high levels of regulation or legislative interference. In Canada, there is an unspoken rule that seems to discourage experimentation and as a result, innovation is stifled. Given how the US is mired in intense health care reform efforts, I don’t see much difference in the US.

I plan to follow-up on this with an updated list of potential disruptive innovations in health care. A few years ago, I wrote a series of posts on disruptive technologies in health care. I think it is time to revisit this issue and focus more on innovation rather than technologies.

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The tablet revisited January 13, 2010

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Yesterday, I wrote about how Apple may potentially release a tablet with a few solutions for the health care market in mind. This blog post explores some possible uses for an Apple-based tablet.

The author reports:

It makes sense for Apple to test the waters in non-consumer markets where tablets have found some purchase in the past. The iPhone is making gains in enterprise, and is even used by many doctors because of the low cost and good design of a variety of medical database apps available on the device’s App Store.

Combining that kind of knowledge repository with a device that can replace a clipboard and act as a connected link to the hospital’s central database would obviously be something that might appeal to doctors. It would reduce the need for extraneous devices and trips back and forth from a central nursing station where information is collected and stored, and could conceivably lower wait times and increase patient turnover, an important concern in privatized health care.

I wonder if organizations will do any usability testing to determine if the handheld iPhone is preferred over a full-sized tablet depending on the role and function of the health professional. From my days working in the hospital, we had anecdotal evidence from staff that suggested that physicians preferred handheld smart-phones (like an iPhone) because they moved around the organization more. On the other hand, nurses seemed to prefer the full-sized tablet because they (generally) worked within a unit. Actually, what the nurses seemed to like best was to have touch-screens mounted on the wall so they could use their hands.

I would be interested to see if there is any data/evidence that examines this issue.

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Is Apple Inc. making its first foray into the health care space? January 12, 2010

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An interesting piece about Apple Inc. purportedly visiting Cedars-Sinai Hospital in California to gauge the interesting and application of tablet computers within health care settings. If true, then this would indicate the first (to the best of my knowledge) company sponsored move toward health care solutions for the company. Apple has traditionally focused on the desktop, education, and consumer electronics industries.

In the past, I wrote about what ehealth (and health care) can learn from Apple, Steve Jobs, and Macworld. Hopefully, Apple can live-up to the now famous Steve Jobs challenge of “changing the world” instead of making sugared water. Making iPhones, iPods, and other consumer electronics devices is great, but imagine what could happen if Apple were to come and challenge the existing players within the health care space…

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Another experience at the ER November 18, 2008

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Unfortunately, I had another experience with the health care system recently – well, not me, specifically, but my dad. He was taken to the ER and so I spent a few hours waiting with him.

The interesting thing was to see Credit Valley Hospital’s new ER. As always, they had the mobile computer stations, but what was fascinating was how little the nurses used them. The nurses spent most of their time documenting on coloured forms which were either stapled together or kept together via clipboard.

Some of the biomedical devices were fascinating too. There was a device that monitored the blood pressure (BP), heart rate (HR), and a few other clinical measures that I couldn’t make out. My dad had something connected to his index finger with some sort of light/laser that presumably measured blood sugar. What was most annoying was that some sort of alarm on the device kept going off every two minutes or so. I tried to make sense of the display, but to my untrained eye, many of the values weren’t very meaningful. I had a chance to watch a few nurses make adjustments to the device and it was very interesting to watch the nurses navigate through the multiple levels of menus using a dial. My friends and colleagues at the Centre for Global eHealth Innovation might be interested in some of the usability/human computer interaction issues. Nevertheless, the sad thing was that this biomedical device was a stand-alone device not connected to any other (as far as I could).

The staff were all very nice, but having worked in the ehealth area for quite some time, I wonder how we can get the indivudal clinicians involved with ehealth. One of the challenges that seem very apparent to me is that using technology is foreign to the daily work process of the clinical environment. Seems like there is much work to be done to get clinicians to adopt ehealth.

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