How I would love to be able to send an email or share an Evernote folder or Dropbox folder with my care team, some kind of shared workspace. My health is a project I’m more than happy to be engaged in, but there’s still that wall, and few ways to share and communicate.
You have to physically call. Maybe the provider calls you back within 24 hours. My care team is phenomenal (I wouldn’t choose anyone else) when they are available and coordinated. Just having to have all communications handled synchronously (face to face or on the phone) is an expensive burden to the system. This alone can more than double the resources (not just my personal wait for a call) required to accomplish a task, which is an exponential phenomenon. It’s like TCP/IP vs a direct connection.
When communication is asynchronous, it can be distributed across time and geography. With a direct connection, it requires a specific amount of time at a specific point in time.
Why can’t we communicate as part of a care team the way people normally communicate and collaborate nowadays? Part of the communication problem in health care is that “the job” has been ill-defined. It’s based on the wrong value proposition: fixing what’s broken rather than keeping the fleet (all of us) running in top condition.
“When the job isn’t well-defined, the team doesn’t know what to include and what to omit. They design based on logical speculations, not real situations.”
This sounds a lot like the disconnect between the presumed, ill-defined goals of most health care interactions and the goals of the consumers and patients.
I’ve been writing recently that value-based medicine is healthcare’s new OS, it has new rules for how assets and resources are allocated. That’s largely because the job to be done has changed. And that means that a whole new way of operating. New processes, priorities and even assets will change. Traditional assets will stay, but many previous liabilities, like communications with patients, will be added to the asset column.
Clayton Christensen made this clear in a recent post on why EHRs haven’t created disruption: they are built on sustaining innovation, not disruptive innovation. For disruption to occur, it will require a new business model with a new value proposition, and new design thinking, focused on the “job to be done.” Hat tip to Bob Coli, MD.
The Business Model
Much like building an overburdened operating system, we’ve been tacking on communication features, procedures and fixes, presuming we know the problems and fixing them in the context that more is usually better, as Christensen sees with sustaining innovation and business models. Christiansen says “sustaining business models tend to provide more complex products, but not lower costs.”
This is related to Ryan Singer’s description of focusing on the wrong goal in product development. In the same article from above, Singer goes on to say:
“Sometimes people think they have defined the problem, but they really just defined a feature. Like ‘users want file versioning.’ It’s important to understand that a feature is not a situation. You can dig into a situation to learn what is valuable and what is not according to the goal. Digging into a feature definition doesn’t do that. It has no origin and no goal. Analyzing a feature definition leads you to play out all the things a person might value from the feature instead of learning what they actually value.”
Value can only be determined by understanding the goals of the user or customer.
In medicine, that’s been an afterthought — after we can bill for fixing the immediate problem. New fixes and new facilities might be better ways of doing the wrong thing. We have a design problem.
An effective design process for healthcare communication might have shared-decision making at the center, focused on patient goals. The benefit for health care organizations is that when decisions are shared, people are much more likely to follow through with actions that support the decision, and make better decisions. (Hat tip to Mike Painter, RWJF)
New Business Model, New Job, New Design, New Assets
Let’s look at the assets and resources that support the business model in a fee-for-service system:
- Physician and other skilled personnel time
- Capital equipment
- Pharma/Biotech research
- Medical devices
- Access to patients, and patient loyalty, (related to outcomes, but not directly)
- Legal protection
- Billing and Revenue Cycle Management
Now let’s look at the assets of a value-based system:
- Scalable communications with patients
- Understanding and influence of lifestyle, culture and behavior in various situations and contexts
- Family, friends and social ties that influence behavior
- Disease management
- End-of-life care
- Scaling effective decisions for physicians and patients, outcomes research
- Sensor networks to understand and predict problems before they occur
- Influencers of health care decision makers, DocGraph could emerge as an example
- Preventative understanding of physician and patient motivation, tools and triggers (Fogg)
- Health IT for patient care, communication and prevention
- All the traditional assets listed above
In a fee-for-service model, the assets are built around limited resources that are expensive to scale: physician time, capital equipment, and EHRs designed for billing. Because these institutions are built for billing.
A switch to value means opening up the opportunity for scaling care.
According to Painter’s report, under the current system “the results of provider-consumer interaction, which are health outcomes for the patient and medical claims billed by the provider, show an overproduction of services with marginal health benefit to the patient. These consequences are evident in the high degree of variability in costs and in the quality of care.”
We’re paying for features, not for the right job to be done; for sustaining innovation, not disruptive innovation.
Value-based payment requires the need to scale and distribute decisions. The more access you have to information and influence on patients and physicians, the better decisions they will make.
Under a new business model, I can see a whole new science develop: cognitive medicine. This science would exam how health care decisions are made, what makes an effective decision, how to influence effective decisions and how to track and scale decisions across time, geography and context with digital tools.
To enable this new business model we need new platform-based systems that can adapt to changing needs and a ton of new information sources, including mobile and behavioral sensors to government data sources (like CMS) to existing EHRs.
Thousands of lives are going to be improved for a lot less money with the communication and the understanding that we’re about to enable. It’s happening much faster than we think.