Tag Archives: creative thinking

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

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.

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.

Rethinking The Benefits Of Expensive Medical Research

In the developed world the really scary diagnoses are very uncommon. More often than not a patient’s symptoms can be safely interpreted as benign. This has engendered a false sense of security because there is evidence that doctors fail to recognise presentations of some nasty diseases.

Innovators in medicine have been focused on this problem for some time. For example a research team reported in 2009 that skin cancer was much easier to diagnose with the aid of a handheld device that draws attention to cancerous changes. The problem however is that doctors need to attend a course on dermatology and take an exam before it is safe to let them lose on people with the instrument. The published report was upbeat despite the fact that one in three doctors didn’t complete the required training. The outcome of this research (and many other research programs funded using millions in taxpayer dollars), was an academic paper that will never impact on the early diagnosis of the disease.

Less than five years later some of the same team were back to test a simpler device but with a similar requirement for education of doctors before successful deployment. The negative results were hardly surprising. The team concluded that cancer was more likely to be diagnosed early if doctors followed guidelines.

History has taught us that just because an intervention may be of benefit to patients, that doesn’t mean it is likely to be embraced by overburdened care providers trying to earn a living. The most successful innovators understand the need to tailor interventions to meet the needs of both the health professional and her patient. They realise that tools that are inconvenient or cumbersome are doomed to novelty status.

Committees that determine which ideas are worthy often deny the lessons of agile, intuitive, creative and effective innovations. These are more likely to be reliable, developed relatively cheaply and don’t need an instruction manual.
How hard is it to adopt your innovative ideas in practice?

Seven trends influencing lean medical innovation

Innovators recognise that the their circle of influence is contingent on an awareness of their customers’ world view. Seven trends now impact on whether people are likely to welcome innovation into their lives.

Mobile communication

For many people mobile phones have replaced their wrist watch, camera and PDA. Phones are now used not only to keep in touch but also to access information with two taps. This is achieved on a ubiquitous device that is getting cheaper and more portable. An allied trend is for tablet computers that are little bigger than a phone to obviate the need for a laptop.

Testophilia

People now demand validity for professional advice that until recently was accepted as gospel because an authority figure proffered it as the truth. This means that you no longer trust me simply because I am a doctor. What’s more people want the results of medical tests in a format that makes sense to them regardless of their ability to digest complex information .

Quantified self

There is an increasing desire to measure and record whatever can be measured as if that in itself will be enough to influence our behaviour. Everything from blood pressure to how much we sleep. Quite what people are doing with all this information is a matter of debate but people are seeking ways to access this information.

Information overload

Because of the almost unlimited source of information at their fingertips people are actively filtering data. A quick Google search for ‘best diet’ revealed 625 million results with page upon page of conflicting and confusing advice. On the one hand you could opt for intermittent dieting or you could take the advice to ditch the diet altogether. As I hold the view that it has to be proved scientifically before it can be deemed true I more or less ignored (i.e. didn’t read) anything that didn’t appear to conform to my own worldview for valid and reliable advice.

Dr. Google.

Concerned people want relief from the outpouring of adrenalin with its unpleasant physical effects. In a Googlised world iving with uncertainty is regarded as unnecessary. This means as a clinician you have to assume people will have done some homework before they speak with you. Either what you say will resonate with their ‘ informed opinion’ or your advice will be rejected unless you are able to say or do something that changes how they feel about their problem and or the treatment.

Commercialisation

The cost of staying healthy increases every year . In Australia the cost of attending a doctor have fast outstripped the rate of inflation. As we age and need more maintenance we will either spend a greater proportion of our income on medicines or look for cheaper alternatives. There is now a compelling business case for marketing cheaper and more effective ways to deal with health problems that until recently required doctors’ appointments.

Want it now

Anyone living with a teenager knows that they no longer accept the wait for Christmas. If you want it, there must be a quick, cheap and immediate way to get it, preferably delivered to your door with a money back guarantee. Therefore speed of delivery is necessary, but not sufficient for success. Innovations that do what they say on the tin, at a reasonable price and come with excellent after sales service are almost guaranteed a bright future.

Lean medicine is about working in a world that has an insatiable appetite for quick, convenient, cheap solutions. The seven trends outlined here have a significant impact on the diffusion of innovation in healthcare. How have they impacted on the success of your ideas?

Innovating at the interface between service providers

At least one in a hundred patients seen in general practice are referred to hospital.

In many countries the referral process hasn’t changed in decades. It’s still done with pen and paper and even in 2013 in some developed countries it still involves a fax machine. What’s interesting about the process is that once the letter is received at the hospital, it is read and then triaged by someone to determine when the patient should be offered an appointment. The decision is made in less than a minute. Everything, perhaps even life or death situations. hinges on the impression created by the writer of that letter.

In a government subsidised system, where there is a need to ration appointments, a patient might be seen next week, next month or six months from now. The reality is that in some cases a patient might wait longer than is ideal and the outcome for them may be compromised, because of what was in the referral letter and how that was interpreted. Who then is to blame, the doctor who was consulted first, or the hospital that arranged a deferred appointment? How can innovation help in this situation?

I’ve been involved on teams that have studied this problem from many different angles culminating in a randomised trial of an innovation in 2012. We came to a number of conclusions. Firstly involving people in innovation when they don’t believe they have a problem is frustrating. Many doctors think their letters are just fine, or that the recipient hardly reads them. Its difficult to innovate in a busy clinic where doctors are working flat out, and the truth is that if the innovation doesn’t make life easier for the doctor as well as the patient then it’s going to be hard to implement.

Secondly colleagues are reticent to demand change from one another, especially when they work in different parts of the system. So, as a hospital specialist I might not feel I have any mandate to require that referral letters contain the details that I like to have. It’s even worse when the paymasters across the sectors are different. In Australia hospitals are funded by State governments, whereas primary care is funded by the Federal government. What’s more primary care providers work to a ‘pay for service’ model. Which effectively means that primary care survives on profits.

Thirdly, it is unsafe to assume that all colleagues apply the same criteria about what clinical scenarios should be allocated an urgent specialist opinion, even within the same specialty, in the same healthcare system, and with reference to nationally accepted guidelines. That was unexpected!

Some problems require a whole systems approach. A problem that has seemingly obvious roots, with a strong(ish) evidence base can be difficult to crack with a lean medicine approach. Where multiple individuals are involved across health sectors, it is absolutely necessary that innovations make everyone’s life easier. Requiring letters to be written a certain way, and demanding that the process is enforced by the recipients, when there isn’t local consensus on what is an urgent case, is not going to work without something else to make it worthwhile for all concerned. What this problem calls for is more innovation when it comes to making the decision to refer. Perhaps more sensitive near-patient tests, which are better able to predict who is most likely to benefit from limited national resources.

What are your ideas for improvement that don’t require people to donate time and effort for no personal gain? Pushing out innovation is not enough, if there isn’t a pull from those at the coalface to adopt those ideas. It isn’t safe, even in medicine, to assume that people will do it, use it or promote it simply because they recognise that patients will benefit.

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?