HIT Innovations Spring from Strategy, Design, and Need

Innovation doesn't always come from a brand new invention or idea. Usually, it comes from  making improvements to something that already exists.

Now Lyle Berkowitz MD, associate chief medical officer of innovation at Northwestern Memorial Hospital, has co-edited an entire book, Innovation with Information Technologies in Healthcare, that riffs on the topic.

Subtitled "The Healing Edge," the book contains a surfeit of stories supporting the idea that innovation isn't the sole province of the wizards at Apple or Google. Rather it  can emerge from the good ideas and brainstorms of designers working in close concert with healthcare providers.

I spoke with Berkowitz last year, and he seems to know everybody who's anybody in healthcare IT. As such, he's a natural choice to edit this 311-page compendium, along with Chris McCarthy of Kaiser Permanente's Innovation Learning Network.

An experimental model for solving problems
The first thing I learned was that innovation can be the result of a methodology. The most common one found in the book is PDSA, which stands for Plan-Study-Do-Act, an experimental model for solving problems. You may encounter PDSA in variations such as Lean (for efficiency challenges), Six Sigma (for quality challenges) and Human-Centered Design (for experience challenges).

Kaiser describes this last methodology in Chapter 2, where McCarthy describes Kaiser's Innovation Consultancy as "an internal design firm staffed by creative people who are part design, part strategy, and part healthcare."

Sounds like a fun and important place to work, especially since the Center is inspired by design firms such as Ideo and PointForward.

Identifying patterns used by technical innovators
The Kaiser methodology parallels that of tech innovators such as O'Reilly Media, which has made a veritable industry out of identifying patterns used by technical innovators. It's through work such as this that the Web 2.0 paradigm was popularized, and we're now seeing insightful pattern recognition being applied to healthcare innovation.

It's a shortcut to spreading innovative ideas more quickly than simply reciting case study after case study.

Having said that, there are case studies aplenty in this book. We learn, for example, that patients at Kaiser wanted to have nursing shift changes happen at the bedside, so the EHR system was modified to allow that to happen.

Low-tech prototyping
The book also discusses the notion of "low-fidelity prototyping, a way to use simple methods to prototype enhanced tools and applications. "It turns out that approximating the tool in another system, such as the [Microsoft] Access database and paper print-outs, can allow for increased efficiency, cheaper cost, faster development and more creativity than trying to do so in the EHR system itself," writes McCarthy and his co-author, Christi Dining RN, director of Kaiser's Innovation Consultancy. Other prototyping exercises involve use of egg timers and simple alarms set on iPod touches.

It's that kind of combination of low-tech, just-enough-technology thinking that we are going to need to get healthcare to where it needs to go. If providers continue to simply turn over a huge list of requirements to vendors (or the government), we're likely to get more overpriced, overproduced technology that doesn't accomplish the mission of making healthcare safer, more effective, and more convivial.

Pathways to process efficiencies
Sometimes innovation simply involves applying a good idea from one part of healthcare to another part of healthcare. By now everyone has heard of Atul Gawande's use of checklists in the operating room. In Chapter 3 of this book, Berkowitz describes application of checklists to primary care and care coordination.

This thinking was rolled into the Inflection Navigator, an EHR enhancement that allows physicians to choose "pathways" to activate care coordinators when significant new diagnoses are made. The first three pathways chosen for Inflection Navigator were hematuria, atrial fibrillation, and cancer. Other pathways will follow.

According to Berkowitz, the system has increased process efficiencies, ensured consistent use of care standards, and provided financial benefits for patients, providers, and payers, and the book goes on in some depth to describe these benefits.

A more-focused workflow
Also featured in the book is an EHR overlay system for coordinating care in use at MedStar Health, the largest not-for-profit health system in the mid-Atlantic region. I learned that MedStar was the birthplace of what eventually became Amalga, a health information system now offered by Microsoft.

At the heart of MedStar's innovation-fueled transformation was a realization that clinicians cannot be counted upon to remember which forms to open and complete in order to perform EHR tasks. I liken this to expecting taxpayers to remember which tax forms they'll need to download and fill out in order to file their annual income taxes.

MedStar and others have pioneered efforts to focus workflow onto a single screen, although much, much more needs to be done in this area. These single-screen prompts also need to be customized to the particular role a given clinician provides in care. Designing those customizations is the tricky kind of detail that is essentially to the success of innovative health information technology, and that this book describes.

Stories from smaller multi-specialty physician groups also find a place in this book. For instance, there's Southeast Texas Medical Associates (SETMA), designated by the Office of National Coordinator for Health Information Technology as one of 30 exemplary practices in the U.S. for clinical decision support.

The screen shots reproduced from SETMA's IT system are a little daunting to me, but then again, they are tracking 200 quality metrics. Still, you can see that ultimately, clinical decision support dashboards are well under construction and in use at many HIT systems today.

In this column, I've just skimmed a few of the many highlights of Innovation with Information Technologies in Healthcare. It takes its place on my bookshelf alongside books such as Connected for Health, which describes how Kaiser implemented its EHR. I'll be writing about that in the future.

For now, hats off to Berkowitz and McCarthy for one of the most useful aggregations of HIT lessons learned that has been assembled thus far.