Researchers’ Look at HIT Development: Are their Perceptions of Co-Development Up to Date?

Oct. 4, 2016
I read with interest an op-ed article in The New England Journal of Medicine entitled “Accelerating Innovation in Health IT." In critiquing provider-based solutions development, did Dr. David Bates and his fellow researchers get it right?

I read with great interest a “Perspective” op-ed article in the September 1 issue of The New England Journal of Medicine entitled “Accelerating Innovation in Health IT.” Authored by Robert S. Rudin, Ph.D., David W. Bates, M.D., and Calum MacRae, Ph.D., the article focused on some of the major challenges facing healthcare IT innovation going forward, as the authors see them.

The op-ed article’s authors get to the heart of things right away. “Even as information technology (IT) transforms many industries, the pace of innovation in health IT continues to lag,” they state in their first sentence. “Electronic health records (EHRs) receive few accolades from providers and have been cited as a major source of professional dissatisfaction among physicians. Despite a proliferation of patient-facing health apps, few have been shown to produce health improvements and many are barely used. The most common IT tools connecting patients to providers are patient portals that so far do little more than provide basic secure messaging and present unexplained clinical data,” they write. “Though many startups and research programs exist and venture capital investment has been growing, health IT success stories remain rare.”

While the authors, Rudin (an information scientist in the Boston office of the RAND Corporation), Bates (a practicing general internist at Boston’s Brigham and Women’s Hospital, and director of its Program in Clinical Effectiveness), and MacRae (a faculty member in the Cardiovascular Research Center in the Department of Medicine at Brigham and Women’s Hospital), tip a collective hat to some of what they see as factors contributing to the problem—“perverse financial incentives in health care that reward volume rather than quality and efficiency, regulations that restrict the flow of information ostensibly to protect patient privacy, and technical integration challenges,” as well as “the multiple demands of ‘meaningful use,’ which have delayed innovation in many areas of health IT”—they focus most of their attention on what they see as “a more fundamental barrier that has not yet received due attention: the disconnect between health IT developers and users. Alternative provider-payment models should create incentives for innovation by rewarding health care providers who use novel IT tools to control cost and improve quality, but the effect of these models will be attenuated unless the developer–user disconnect is addressed.”

The authors zoom into one key issue. As they put it, “Health IT developers typically work in one of three settings — established IT companies, startups, or academic research departments — where they have little to no contact with patients and clinicians and therefore often lack a deep understanding of users’ needs. Established IT firms, most notably EHR companies, have adhered poorly to user-centered design principles, despite federal certification requirements that they apply such principles.2 In startups, developers are typically young and healthy, with little firsthand knowledge of clinicians or the chronically ill patients who consume most health care services. Much of venture capital is therefore clustered in wellness companies making products such as fitness trackers that cannot help the patients most in need and thus will have little effect on health care costs.”

Now, here’s where things get interesting. The authors do acknowledge the existence of incubator organizations—about which I’ll say more in a moment. But they write this: “Some health care incubators are producing startups that target clinicians and chronically ill patients, but we believe that these organizations generally underestimate the effort needed to understand such complex and diverse users. Some academics have focused on understanding users’ needs, but efforts tend to be small and fragmented and to involve multiple years of development. Rarely do findings make their way into the design of novel functionalities, for which relatively few funding sources are available.”

So this is where I think that these authors are perhaps minimizing unnecessarily the potential for test beds that are springing up at a number of major integrated health systems, among them Intermountain Healthcare in Salt Lake City, the Mayo Clinic in Rochester, Minnesota, Cleveland Clinic, Geisinger Health in Danville, Pennsylvania, and most ambitiously, the vast UPMC health system in Pittsburgh.

The reality is that these large, integrated health systems that have a great deal of financial resources and the potential to produce commercializable IT solutions, are quite serious about moving forward on this path. As I wrote in June, while visiting the folks at UPMC in Pittsburgh, “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 I wrote about my meeting with Shvidev (Shiv) Rao, M.D., the director of clinical innovation strategy at UPMC Enterprises, and a physician who 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.

Dr. Rao noted that “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,” he told me. “But where we see green space, we’ll build it ourselves.”

And what was most impressive was to have him explain to me an idea that he and his colleagues conceptualized and have been pilot-testing, which he described to me as “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.” As he pointed out, “On the surface, this appears to be a very simple application,” he noted, “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.”

Dr. Rao was speaking to something deeply true about all of this: that many of the best apps that are going to emerge in healthcare IT are going to be developed with the full participation—sometimes even starting with the ideas of—physicians, nurses, therapists, pharmacists, and other clinicians. What’s more, when I asked him what the world of tools for specialist physicians needs to look like, he said that, “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.”

Now, when I think about what Drs. XXX have said about the gaps in healthcare IT innovation, and what UPMC’s Dr. Rao told me earlier this summer when I met with him in Pittsburgh, I find that the two sets of thoughts are not irreconcilable. What the NEJM op-ed writers have stated—that many corporate healthcare IT developers are quite detached from physicians, nurses, and other clinicians, and their clinical worklives—seems demonstrably to be true. Meanwhile, their contention that “Some health care incubators are producing startups that target clinicians and chronically ill patients, but we believe that these organizations generally underestimate the effort needed to understand such complex and diverse users,” is one that is being challenged at a range of organizations, including UPMC, Intermountain, Cleveland Clinic, Mayo Clinic, and Geisinger Health System, among others.

In fact, it appears that the batting average at UPMC in particular is turning out to be pretty good so far, with several solutions becoming successfully commercialized. And, apart from which specific health systems are doing the developing, it seems clear that many of the most useful clinical apps and other IT solutions are going to come out of these patient care organization-based test beds or incubators. When one thinks about it, it makes perfect sense. A lot of clinical IT solutions have in the past been developed with minimal or inadequate clinician input and participation, and that needs to change. As U.S. healthcare moves forward, there is no need for solutions that don’t actually solve the problems that clinicians face in their essential work.

So let’s see how the provider test beds that have begun to spring up, evolve forward—while hoping that the clinical solutions work taking place at organizations like UPMC opens up and becomes possible for a wide variety of providers, not just the most richly resourced ones.

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