All posts by Moyez Jiwa

The secret to lean health innovation is harnessing the truth

In the later 1990s when I was practicing in a 7,000 patient practice in England we had a system of five minute appointments. Five minute appointments that were really ten minute appointments. In most cases a doctor can’t achieve anything useful during a five minute appointment. Some doctors would argue that ten or even fifteen minutes is scarcely enough. However this was how it had ‘always been done’ so the new doctors to the practice adopted the system that was in place. By the time you got to the last patient in every surgey you were running at least half an hour late. We were kidding ourselves—nobody ever finished by 11am. We were still consulting at midday and then rushing off to do home visits stuffing a sandwich in as we drove from patient to patient. We were back at the surgery by 2pm ready to start the whole thing again—intending to finish at 5, but in reality turning off the lights after everyone had gone at 6.30pm.

The data was right under our noses. Some doctors were known to ‘always run late’, others became adept at pushing patients in an out quickly with a prescription in their hand and instructions to return next week. Patients learned to choose the doctor they thought was best for them, whether that was one who would ‘get to the bottom of it’ or give you a prescription and a sick note but couldn’t be relied on to know when you had cancer.

Consulting style does impact a patient’s choice of doctor. and doctors and patients don’t always share the same view on their consultations.

Meanwhile back at the practice resentments festered because some doctors were having coffee in the staff room at 11 while their colleagues were still working through the list until nearly midday. There were suspicions that the early finishers were seeing fewer patients and never around when the emergency walk-in turned up at 11.45. Stressed doctors couldn’t see what was already evident to everyone else in the practice—we needed to redesign our appointment system and tackle issues engendered by our own delusions. In the end, as a practice, we needed to look at how each practitioner was consulting and how this was reflecting the practices’ values to its patients.

Something had to either change or give and we decided that if it wasn’t going to be us or the patients, then it had to be our system. We had to face the truth that the numbers of patient appointments we scheduled during the day was greater than our capacity to treat them properly in the time we allocated.

Our colleagues in other surgeries thought we were ‘brave’ to move to ten minute appointments. There were implications for radical changes to our appointment system. But the first thing we needed to recognise was that our schedule must treat our patients as if their time mattered at least as much as ours. It was, and is, unacceptable to keep patients waiting because we don’t want to accept reality. This denial leads to patients failing to keep their appointments, choosing to go elsewhere and it ultimately leads to doctors burning out.

We didn’t need a big R&D department to tell us what our staff and patients would say if we bothered to ask. I now work in Australia and still see the same patterns here. My friends tell me you can count on this doctor to prescribe antibiotics no matter what is wrong with you, and that one always gets to the bottom of things but prepare a packed lunch when you make an appointment with him.

Our time is not more important just because we are doctors. Innovation sometimes involves taking responsibility not investing in a new computer program or running a focus group.

Putting the patient first is not just good medicine, it’s good business

Primary healthcare is mostly organised as if all patients had the same needs. Patients who have a chronic illness who are repeat visitors and those with significant risk factors for future disease, are expected to fit into a system that is designed to meet the needs of someone with urgent and temporary illness. The current system is designed as if it doesn’t really matter which doctor consults them or what is known about their needs.

These are the facts:

1. Each week, there are 1,700 new cases of dementia in Australia; approx. one person every 6 minutes.

2. Cardiovascular disease affects one in six Australians

3. In 2011/12,4.6 million Australians(32%)aged 18years and over had high blood pressure (systolic or diastolic blood pressure is ≥140/90 mmHg or taking medication). Of these, more than two thirds (68%) had uncontrolled or unmanaged high blood pressure (not taking medication), representing 3.1 million adult Australians.

4. 1 in 2 Australian men and 1 in 3 Australian women will be diagnosed with cancer by the age of 85.

In some cases patients are expected to make appointments at a time and place that suits the practitioner. They might be seen for as little as 10 minutes and can feel that their questions and concerns have been addressed. The consequence is that both the doctor and the patient become frustrated.

The clinician complains about workload while the patient seeks alternative ways to meet their needs. There is published evidence that patients with chronic illnesses have significant unmet needs that impact on their quality of life.

The lean innovator knows that the future success of healthcare depends on serving the needs of those who are likely to need to consult a doctor many times in coming years. These patients need to live life despite pathology and to care for others even when they are not feeling their best. The person with enduring health problems also needs to believe that their doctor knows them, understands their perspective and has their best interests at heart.

In the business world such a loyal customer is prized. The business strives to make them feel valued. Great businesses constantly reinvent themselves and look for new ways to ensure that the customer is happy with the service on offer. It takes relatively little to satisfy the patient in a primary healthcare setting. We know, but sometimes forget, that what the patient craves most of all is their doctor’s undivided attention. Like a customer in any other business our patients want to feel that they matter.

We don’t need a department or a huge budget to innovate, because as both business owners and doctors we have the authority and insight to redesign how the patient feels from the moment they walk through the door and at every stage before and after their appointment.

If research has taught us anything it is that the fundamental need in healthcare is for their doctor to have good communication skills. Without that foundation nothing that technology can do for the patient will ever be good enough. Every touchpoint of the system needs to reflect the experience in the consulting room and should say to the patient—we know and care about you.

What is the most important thing you do for the people you serve? Do they get a sense of that from the moment they look for your help?

Why the future of health lies in thinking small

General Practice in Australia is a private business. There are 7200 GP businesses in Australia, with a revenue of $10bn per annum. Each practitioner is estimated to earn $200,000 on average. 95% of the income for these businesses is derived from government rebates, mostly from 10 to 15 minute consultations. The concerns of the practitioners in this context are said to be:

1. Threat of litigation

2. Too much work to do in a limited time

3. Earning enough money

4. Patients who are difficult to manage

5. Paperwork

6. Intrusion of work on family life

7. The cost of practice overheads

8. Time pressure to see patients

9. Unrealistic community expectations

10. Negative media comments

Increases in the Medicare rebate have failed to keep pace with the rise in the costs of running a GP service with increased patient throughput often used to make up the shortfall. Where this and other barriers exist, it may not be feasible for patients to be offered additional advice or services beyond their original reason for presentation unless a strategy is negotiated and agreed between the relevant players.

We know that the healthcare needs of patients are set to change in three important ways:

1. The population is aging.

2. There are more effective, albeit ever more expensive treatments available.

3. Poor lifestyle choices, linked to obesity will generate greater demand for medical appointments.

We are therefore relying on private businesses to respond to growing need in the knowledge that they are already working to capacity.

Under the central set of assumptions used in this study, total health and residential aged care expenditure is projected to increase by 189% in the period 2003 to 2033 from $85 billion to $246 billion—an increase of $161 billion….This is an increase from 9.3% of gross domestic product (GDP) in 2002–03 to 12.4% in 2032–33. Increases in volume of services per treated case are projected to account for half of this increase (50%). Projection of Australian health care expenditure by disease, 2003 to 2033

Another unique aspect of the business of medicine is that despite its technical and scientific basis, medicine is most effective when the human interaction between practitioner and patient is at its heart. Efforts to interfere in the process through the revision of payment schedules are only partially successful if not actually harmful.

The commercial reality is that without innovation, primary care as a business will not keep up with demand. To date evidence in practice is that researchers in primary care often fail to engage with clinical partners and innovation is stymied. Government investment in innovation in primary care is on the one hand conservative and limited. Ninety percent of government funded healthcare is delivered by small businesses and yet over 90% of government investment in research and innovation is targeted elsewhere. What little is funded is usually awarded to competing tertiary institutions whose performance is measured on academic outputs rather than impact on practice.

These are the foundations for a lean, agile, creative, approach to innovation  based on commercial reality and factoring in three key elements:

1. The most expensive component of innovation is establishing the problem and creating a value proposition that  factors in the perspective of end users.

2. Innovation only ever works when it is driven by a champion willing and able to re-engineer multiple prototypes to solve the problem.

3. There are opportunities for commercial partnerships if the key performance is reframed in the metrics of sales.

The conditions already exist for this approach to innovation in the business of primary care. Primary care in many countries, like Australia, is led by highly creative, intuitive problem solvers, many invest their insights and energy on small projects that have the scope for substantial commercial returns but more importantly to deal with the coming tsunami of health related problems. The final word is to Paul Graham:

People are bad at looking at seeds and guessing what size tree will grow out of them. The way you’ll get big ideas in, say, health care is by starting out with small ideas. If you try to do some big thing, you don’t just need it to be big; you need it to be good. And it’s really hard to do big and good simultaneously. So, what that means is you can either do something small and good and then gradually make it bigger, or do something big and bad and gradually make it better. And you know what? Empirically, starting big just does not work. That’s the way the government does things. They do something really big that’s really bad, and they think, Well, we’ll make it better, and then it never gets better.

The lean innovators’ insight

Simple access to medical records is a strategy for failure. Generate value to patients…people… then medical information and tools. Please do not reverse. Grant Taylor

When it comes to defining the value proposition lean innovators have a substantial advantage. They know that some innovations won’t work because:

1. They take up time that should be spent listening to the patient.

2. They require the practitioner to learn a new skill.

3. They are good for the patient but add an administrative load.

4. They assume the patient will invest time and effort on collecting information that has no apparent benefit to them.

5. They obviate the need for physical contact with the patient.

6.  They demand time and energy without solving any immediate problem.

Lean innovators- clinicians who practice their art-know this because they’ve been in the moment with those intended to benefit. They’ve sat opposite the person in crisis , the person who struggles to function or has to redesign their life and revise their dreams because of some all too inconvenient health problem. To that person it isn’t about the latest gadget or gizmo, they do not care if it helps the system to collect data. They want tangible benefit, they want human contact for which no device is a substitute and the lack of which reduces the potential for recovery and regeneration. For the practitioner an invention should fit seamlessly into their way of working and earning a living. The innovator knows that if an innovation is resented as an intrusion in practice, that end users will actively search for reasons that it ‘doesn’t fulfill its promise to patients’. Result: another promising idea shelved, another innovator frustrated.

Funding creativity

The organisations or institutions most able to fund and promote creative solutions have the resources but it is unusual for them to embrace novel ideas. Perhaps because they are accountable to stakeholders, risk averse and have rigid governance structures enforced by people with no stake in the outcome, rewarded instead for enforcing process. Decisions taken by such organisations are vulnerable to influence. Here are ten ways competitors stem funding for novel ideas:

1. Nominate: Get nominated as a grant reviewer on a funding committee on the basis of ‘expertise’ in their field.
2. Spook: Express concern that the applicants don’t seem to be aware of other funded projects on the same topic. Committees are easily spooked by the idea that applicants might be generating ideas that compete with something that has already been funded. The details don’t matter as long as whatever the committee ‘expert’ cites sounds like it might be relevant.
3. Foster doubt: Express concern that in their ‘expert’ opinion the project won’t succeed especially if the applicant could be accused of being unfamiliar with the context in which they intend to operate. Committees will be relying on their member’s special ‘expertise’ and are unlikely to disagree.
4. Cast aspersions: Note that the applicants don’t have the relevant expertise. It needs some imagination but always possible. No one is accomplished in every facet.
5. Magnify: Make much of reports that the pilot studies were inconclusive and by corollary risky. Novel ideas usually are. If the pilot studies showed promising results they make the remark that further research of this untested, risky idea is therefore probably unnecessary.
6. Argue: Present arguments why the budget requested is too high- in the current economic climate there is always room for economy. If the grant is approved having the budget slashed should slow competitors down.
7. Impugn: Comment that the chief investigator doesn’t have a strong enough track record to deliver on this project. Innovators doing something new are unlikely to have done anything exactly like this before. It spooks committees who might worry about any possibility that the money will be wasted. Sexism and racism, when it is subtle makes this easier.
8. Choose: Find another project on the list, led by someone who isn’t a threat, that is ‘so much better’ and of course less risky and would make a ‘big’ difference in practice. Committees would be happy to hear that the subject expert thinks they’d be funding something that would be so much more likely to meet a need.
9. Gossip: Express concern that even though they don’t ‘know’ the applicants personally, they’ve heard rumours that the applicants don’t produce good work. The doubts should generate enough anxiety to make some reviewers rethink their enthusiasm for a project.
10. Ambush: If such attempts at heading off the applicants at the pass fails and the committee funds the project- there’s always a chance for a competitor to stop them publishing their results later on. There’s lots of scope to recommend rejection of any paper- inadequate literature reviews, debated methodology, concerns about sample size, participant attrition, conflicting ideas about analysis of the data, failure to acknowledge the limitations of the methods. If all else fails someone can always find typographical and formatting errors that cast doubt on the whole manuscript- after all there is ‘lots of competition for space’ and the best journals receive ‘so many more papers than they can publish’.

On the other side of the fence if you are a determined innovator there is an opportunity buried here. On whom does your future depend if not on yourself? How do you innovate in a world that is viewed by some as being so small that if you have even a little then they don’t have enough? How are you being so resourceful that this doesn’t matter? A lean medicine approach is not about big projects nor reliant on big grants. Lean medicine is fuelled by the imagination and resourcefulness of champions.

Where do innovators start?

Lean innovators can’t help themselves. They see ideas every where. Inspiration is to be found where ever there is a problem and healthcare is full of problems. I’m going to mention three problems:

1. Health care is rationed. Even in countries where it appears to be on tap- it is rationed. For example when it was launched by Britain’s then minister of health, Aneurin Bevan, on July 5 1948, the national health service was based on three core principles:

That it meet the needs of everyone
that it be free at the point of delivery
that it be based on clinical need, not ability to pay

No one believes this is true and the experience of many is that even if it is ‘free’ you may still have to wait for it even if your need is great- simply because the ‘gatekeeper‘ doesn’t recognise the urgency of your need. Here is scope to innovate.
2. Health care is organised around the needs of the provider. In many countries you have to make an appointment at a time, and a place that suits the practitioner. This might mean taking a day off work, traveling a long distance, sometimes, as in my country several hundred kilometers to consult the expert. It is possible that you don’t fit the mould designed for the ‘patient’ in that system. Your culture may clash with the provider- so that you struggle to be understood, cause or take offense and generally find that things are lost in the translation. Consequently inequity characterizes most if not all health care systems. Another prime opportunity to innovate.
3. Health care can harm you. It is possible, some would say probable that at some point in your life the drugs or procedures designed to relieve your suffering may actually harm you or at best do nothing for you.

Simply being a patient in an acute care hospital in Australia carries, on average, a 40-fold greater risk of dying from the care process than from being in traffic, and a 400-fold greater risk than working in the chemical industry.  Australian Patient Safety Foundation

Further honing the indications for tests, prescriptions and procedures may do much to improve outcomes for most of us. For example it has been shown that the participants in trials of most drugs bear little resemblance to those for whom those drugs are prescribed in practice.

Although 61% of new cases of cancer occur among the elderly…..studies indicate that the elderly comprise only 25% of participants in cancer clinical trials.  J Clin Oncol.2003 Apr 1;21(7):1383-9.

Similarly potentially harmful tests are performed unnecessarily and many invasive procedures are carried out for dubious reasons. Finding ways to reduce the scope for harm is therefore a priority.

Why innovators should learn to embrace feedback

Lean innovators often work in isolation and not surprisingly the innovator is emotionally invested in her idea. She has conceived the idea, developed it, spent time and resources on bringing the idea to life. This makes criticism of her brain-child very hard to bear.

The temptation is to be defensive. To shout down the critic. To take the view that the person offering an opinion hasn’t understood the brilliance of what has been brought to the world. The cure for this sort of pain is to begin with the end in mind.
Consider who is this innovation is for? Who needs to cooperate to make it available to the end user? Who will pay for it, either with hard cash or with their time and effort?

Another way to get a better understanding of the real problem you’re trying to solve is to write a short letter to the person you want to solve the problem for. A crucial part of innovating is to tell the story of the invention effectively, to make the people who need to care in that moment, care. It’s worth investing the time to get your story right and to seek out people you trust to give you honest feedback before you have to tell the story for real.

Instruments of measurement vs. instruments of connection

9597562683_0f1bb9156a_zMany health innovators argue that future advances in health care will come from technological solutions. Things we can measure and quantify. Governments and health care providers are holding their breaths for a magic bullet that can easily, measure and thus fix everything.

People who advocate for technological health solutions think that it’s possible for doctors to routinely consult patients without touching them, or even looking them in the eye.

Stakeholders imagine that that health practitioners spend time with their patients simply to gather and process data. We imagine a future when a patient’s wearable device will be handed over to the doctor, who will have everything he needs to know and more, in order to treat any ill.

That is not to say that we should not innovate, or that technology will not enhance the encounter between patient and healer. However we do need to think about how those innovations will become part of that powerful ritual known as the medical consultation. Technology, high tech or low tech, needs to be incorporated in a way that responds to the person in distress. It should be seen as a means to an end, and not an end in itself. If information was all that was required to get people to adopt healthy choices then why do we make so many decisions that defy logic?

Science has identified that people act on impulse, are moved by emotion, or commit themselves to decisions because it makes them feel good even if they know it’s doing them harm.

The reality is that not everything that matters can be measured. Patients don’t just come to doctors to be fixed. As health care practitioners we mustn’t lose sight of the fact that what patients need as much, (if not more) than, instruments of measurement are instruments of connection.

Picture by Alberto Varela

The importance of touch in the medical consultation. There is no app for that

When people are scared or in trouble what they want most is to be touched. Information alone is never enough to satisfy the deepest human needs that bubble up when our bodies appear to malfunction. This was recognised generations ago and the role of doctor was socially ordained. Doctors are licensed to examine the body intimately. Any doctor who abuses this trust is severely punished. The examination provides the healer with the information required to make a diagnosis, but more importantly it comforts the sufferer through human contact.

When I was a ‘wet behind the ears’ GP trainee, my clinical mentor offered me two pieces of advice in relation to the medical consultation. He told me to always stand up to greet the patient as they walk into the room and to look for an opportunity to lay hands on the patient, even if only to take their pulse.

Innovators may be tempted to think that everything that takes place in the consultation can be distilled down to the exchange of information and advice. However the consultation is designed to promote healing by allowing people to express concern and empathy through verbal and nonverbal behaviour. The former requires excellent communication skills, the latter is conducted as a series of rituals: ‘inspection, palpation, percussion and auscultation‘. And even as the body is examined the patient needs to feel that the examiner is concerned and respectful. If this is done well, healing can begin, sometimes against the odds.

This has important implications for innovation in health care. It’s not possible to interrupt or diminish the direct association between the doctor and the patient with gadgets or gizmos. If we do we may lose more than we gain.

Why aren’t healthcare providers doing more to tackle the biggest health problem?

Obesity is the single biggest health problem facing our generation and the generations to come. It’s already killing, disabling, disfiguring and demoralising more than half of the population in most developed countries. By 2025 the majority in the developed world, and a growing proportion in the developing world will be overweight or obese. We have seen it coming, the warnings have been around for decades and yet we have done very little to combat it. Now it’s reported that doctors can’t see what they can do about it.

Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.

—Laura Epstein and Jane Ogden

The reality about the problem of obesity is:

1. We are all aware that being overweight is harmful and yet we are legally bombarded with subliminal messages that promote unhelpful lifestyle choices .

2. It may be counter productive to raise the issue with someone who already feels a sense of shame and guilt.

3. Simply being offered dietary advice by a health practitioner isn’t making a difference to most people. We already know what we shouldn’t put in our mouths, that an apple is better for us than a chocolate bar.

4. People find it hard to do what needs to be done to tackle the issue—eat less and exercise more. It’s hard to sustain the effort over a period of time and to make permanent lifestyle changes.

5. Our current healthcare interventions and innovations with regard to obesity are not working.

6. In Australia the cost of dealing with the effects of obesity has reached $120 billion. We are not doing enough to tackle the root cause.

7. We must find a sustainable solution to this problem. Handing out diet sheets and making referrals to dieticians is not enough.

The challenge, for the practitioner is to present information that’s hard to hear in a way that it is likely to be taken on board and acted on. To appeal to how people feel about making changes, not just what they know. To provide information that is motivating and affirming. To reduce the time burden on health practitioners to deliver that advice efficiently. To put the tools into the hands of the person who may have to change life long habits. We just need the collective will to make it happen.