Learning from Doctors in Practice, Pushing Towards Innovation

April 10, 2013
Northwestern Memorial’s Lyle Berkowitz, M.D. wears many hats—and he sees the elements involved in facilitating healthcare delivery and healthcare IT innovation from a variety of angles, as a physician informaticist in both the outpatient and inpatient spheres, as a practicing primary care physician, as a blogger and book editor, and now as a software innovator.

Lyle Berkowitz, M.D. has nearly as many professional titles as he has professional affiliations, involvements, and activities. He has been long-time medical director of IT and innovation for Northwestern Memorial Physicians Group (NMPG); and was also recently named associate chief medical officer of innovation for Northwestern Memorial Hospital, the academic medical center located in downtown Chicago with which the multispecialty NMPG is affiliated. He is also a clinical associate professor of medicine at the Feinberg School of Medicine at Northwestern University, and director of the Szollosi Healthcare Innovation Program. In addition, he recently co-founded and is chairman of healthfinch, a software firm building "doctor happiness tools" which integrate with EMRs to improve office workflow efficiencies.

In addition, late last year, he published a new book, Innovation with Information Technologies in Healthcare, of which he is co-editor. And in his “spare time,” he blogs at The Change Doctor.

Clearly, Lyle Berkowitz is a busy man. But he took time out recently to sit down and speak with HCI Editor-in-Chief Mark Hagland regarding the recent evolution of his thinking around healthcare IT innovation. Below are excerpts from that interview.

With regard to Innovation with Information Technologies in Healthcare, Marion Ball [Marion J. Ball, Ed.D., professor at the Johns Hopkins School of Nursing, and a consultant with the IBM Center for Healthcare Management] approached you about creating a book combining healthcare IT and innovation?

Yes, Marion knew that I was very involved in both the informatics and innovation worlds, and brought this idea to me. I wrestled with the question of whether it should be more about innovation or about IT. As I discussed it with my colleague (and eventual co-editor) Chris McCarthy, who leads the Innovation Learning Network (ILN), it quickly became clear that this book should be a series of stories about innovative uses of HIT.  Furthermore, we needed to tell them in a way that would educate and help readers without being overly dogmatic, and would explain to them that you can readily innovate with the technology you already have now.  So the first third of the book has stories about innovative uses of electronic medical records (EMRs), the second third has stories about innovative uses of telehealth, and the last third covers innovative stories with more advanced technologies.

We started the book by creating a narrative for the imaginary Ramirez family, and we asked each author to consider how their innovation would affect this family.  This was a fun way to ensure similarity of voices among the authors, while also nurturing the individuality of the different authors’ situations and stories.  Most of the innovations [presented within case studies in the book] were pretty well-baked, though a few were still pretty early in their development. But in all cases, there were a lot of lessons that had already been learned. In some cases we even went back in time to get the stories of past innovations which still have relevance today, such as the history of one of the first patient portals. Now it’s not as though patient portals are that new anymore, but we went back to the time and place when patient portals were new, and asked the early pioneers from Partners Healthcare what the conditions were like then and how they figured out what to do.

A key point in all of this is that innovation is not about the technology.  In fact, there is a science and methodology to the art of innovation which we see in numerous ways throughout the book. To help orient readers, in the second chapter we defined many of these innovation methods, and explained how they apply to information technology in healthcare.

Lyle Berkowitz, M.D.

How do most innovations start - is it usually via some sentinel event?

We did ask the authors about this - and each chapter has section explaining how and why an innovation began in the first place.  Often, there was a sentinel event, but there was also a champion for change.  The result would be a change in process, technologies, and/or business models. In some cases, people actually changed state laws which needed to evolve to today's realities!  But the tough part is culturally doing something new, and making sure everyone feels comfortable about it.

Are you perhaps impatient that there’s a lack of deep thinking about some things in the industry right now?

Well, I love my colleagues. But in the innovation world, it’s so important to observe and listen. And often, I find that doctors in general have a very normal habit of saying, “Something bad happened. There’s something wrong with it! What’s wrong?” And I say, “Well, wait, let’s step back and examine everything that happened.” There’s this saying in consulting about the five whys and ten hows. It’s an innovation technique to understand what someone’s really thinking. I get e-mails every day from my partners, who will say something like, “The system’s broken, and this order came to me when someone else ordered it. We have to rethink the whole system!” And I’ll ask, well, why did that happen? Well, because someone typed it in wrong. Well, why did that happen? And ultimately, you have to ask, how can we fix this? But we need to be cautios about not jumping to conclusions before exploring the correct questions and big picture goals.

I like to say, I’m a lazy doctor, I don’t want to add three steps to make it better, I want to take away five steps and still make it better. I am a big proponent of figuring out how to get the electronic medical record and related systems to do more of the work. And a lot of this theme resonates through the early chapters of the book. How can the EMR automate the process and delegate it to the appropriate people and processes? There are three chapters all addressing this common idea of automation and delegation of common office workflows, but they are implemented in three different ways through three different EHRs [electronic health records]. It’s important to see both the commonalities and differences in these approaches so one can then apply it to their own situation.

Overall, are people on the mountains we collectively need to climb in healthcare?

Well, as always, there’s no simple answer. But many medical informaticists are problem-solvers, and we use technology as our lever. And so many of the great innovations in the book are fundamentally process innovations, not technology innovations. But it turns out that it’s so much easier to spread innovation when it’s embedded in technology. And we’re often the types of doctors who in the past might have created little innovations for our own individual offices to make them work better; but now we can create and diffuse systemic solutions.

The best CMIOs are able to see the forest for the trees and be able to understand that their job is so much more than implementing a system; it’s creating a solution to a problem. And the innovators in the book all realized that their job included leveraging technology, but certainly didn’t end there; instead, innovation always requires cultural and process elements to be included in change. We know we are headed towards an unsustainable cost curve in healthcare.  But when HMOs first emerged, as “managed care 1.0,” we didn’t have the tools to make it work. Now we do have the tools. And CMIOs have to help their colleagues figure out how best to leverage tools to improve quality, reduce costs, improve efficiency, etc.  Part of our jobs is figuring out what can and can’t be done technologically in a reasonable way, but also understanding how to lead our colleagues.

To that end, it’s so important to understand all the cultural and process elements involved in making any changes.  A good example is meaningful use. I was one of the early skeptics in terms of meaningful use, in that I said it's unlikely to get massive adoption quickly. I wasn’t against it, but I agreed there was some unrealistic optimism at the start of the process. And if I’d had all the money to use, I might have built some standardized EMR structure, and had everyone move to that as a platform. But MU has indeed stimulated adoption and pushed users to do things they might not have necessarily done on their own.  For example, since MU requires us to document about smoking in a structured way, it forced us to rethink how we capture and use that type of information in a way that was indeed more meaningful.

I would love it if ONC [the Office of the National Coordinator for Health Information Technology ] would give us a bit more flexibility in terms of how to fulfill their requirements, but otherwise, it’s worked out very well. Some people said that it hurt innovation, but in fact, I think it has created a more consistent platform on which to innovate. And the true innovations will come from the providers and from the small companies that will build innovations on top of EMR platforms, via companies such as Allscripts, athenahealth, and Greenway, which are allowing for the creation of open apps. And that’s extremely important, because it will allow for the creation of market-changing tools that the large vendors simply haven’t had the time to focus on, since they are so busy just keeping their trains running on time.

You have strong feelings about what it takes to optimize the assigning of medical informaticists to help drive both EMR/EHR adoption and process innovation, correct?

Yes. Innovation so often comes from the front line; so we have to ask our doctors, nurses, care coordinators, and staff how the EMR might be made better. Let’s do a better job at watching them work and figuring out what they need.  People will often say they want something, but they don’t recognize what they really need. In fact, so often, the best innovation comes from simply watching people at work. A lot of people think that simply having a 23-year-old with a degree in design interface will help them make their EMRs more usable; but in fact, actually watching physicians in the field—that’s where you’ll find some of the best improvements in usability. And not going out for a few hours, but literally spending days and weeks at a time, and coming back to show the end users the design in a consistent iterative process. We’re starting to see the vendors become more open to that, but it’s a gradual process. And the best thing is that for me [as a medical informaticist still practicing medicine]: I have to eat the dinner I’m making; I have to use the systems I’m helping to build and implement. And while all CMIOs have different responsibilities, I hope they all still make time to watch what their front-line doctors do, and take cues from them.

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