better health by designLearn More

Testing assumptions before innovating

Successful innovations are based on addressing ‘real’ problems. They are not founded on assumptions that haven’t been tested. All too often we are presented with ideas that don’t really address the problem from the perspective of the end user. Usually these innovations are designed to solve someone else’s problem and then foisted on an unsuspecting end user. The result is the creation of yet another problem and worse of all wasted resources at a time when economies are under strain.  There is another way. In a very generous contribution with a more sensible approach Julius Parrisius offers this brilliant slide deck. It involves actually finding out what the ‘client’ aka end user needs from you to get through their day, what they find challenging about the problem in question and what’s on their wish list.

The issue in healthcare is that many value propositions are hard to pin down, either because the circumstance are relatively uncommon or because people don’t want to talk about them. They include people presenting/ experiencing:

  • Cancer symptoms- especially the kind that involve embarrassing symptoms- diarrhoea or offensive discharging from unmentionable orifices.
  • Psychosexual problems
  • Sexually transmitted disease
  • Substance abuse
  • Death and dying

Sure you can organise focus groups with a handful of ‘representative stakeholders’ but are you really going to get to the truth? The whole truth? There isn’t really a better way then observing the interaction between practitioner and patient. The challenge is that no one wants you or your video camera in the room while they confess their problem and the care professional doesn’t care for this either. Ethics committees tend to agree. What’s more this preliminary, hypotheses generating research is seldom funded by anyone and sounds daunting- much more so than calling up a friendly ‘stakeholder’ from your list and taking it for granted that they know what they are talking about. So you enlist the ‘support’ of your token end user on one of your ‘project steering groups’ and then hope and pray that they haven’t misled you. Unfortunately it can persuade grant committees that you have done your homework. They won’t find out until they read the press following a launch of your baby and discover that other end users don’t agree. Then you…start again, if anyone still trusts you.

The other issue is that you may also uncover evidence that could land the professional end user into some difficulty-failure to provide evidence based practice with actual patients cannot be overlooked if it is likely to put people at risk in the future. You have a responsibility to protect people- notwithstanding your role as innovator. So, where to from here? How do you get behind closed doors without interrupting the business at hand and while also allowing the practitioner to demonstrate their ‘pain’ with this problem/ issue? Our team has done well deploying simulations. It has allows us to generate and even test hypotheses in an environment in which people have not been put at risk and also relatively quickly allowed us to duck blind alleys before we were committed to them. The key is to accept that the rubber always hit the road when the person with the problem seeks help- in our setting that is usually when they present to a general practitioner /primary care physician/ family doctor and therefore the stage, the props and the actors are already defined- all we have to do is produce enough of the script to let the cast develop the plot- the rest is done by the participants and the truth will out.

Innovating for exemplar conditions

Colorectal Cancer (CRC) impacts on every part of the healthcare system. If a solution can be found to the challenges associated with CRC then they can probably be found for dealing with many other chronic and complex conditions.

  • CRC is one of the commonest malignancies in the developed world and often presents too late for curative treatment.
  • It may be related to a poor diet and is associated with obesity. The incidence is rising.
  • The vast majority of CRCs present with embarrassing symptoms.
  • Such symptoms are common and are also features of benign disease. People find it difficult to decide when they should see a doctor.
  • They often choose to consult other than a medical practitioner and there is evidence for procrastination and for inconsistent advice from the other healthcare providers.
  • [We need tools to assist those healthcare providers to signpost people to a doctor. Such tools need to fit seamlessly into their way of working]
  • The investigation of lower bowel symptoms are invasive and involve unpleasant intimate examinations.
  • Men are more likely to delay consulting a doctor than women.
  • [We need to understand why that is and what we might be able to do about it.]
  • Eventually anyone who develops CRC has to visit a doctor occasionally as an emergency. Symptoms may not correlate to the severity of the disease.
  • Those at highest risk of cancer are older people with lots of other problems.
  • They are all referred to a surgeon. Sometimes the diagnosis is delayed longer than it need be.
  • The treatment of CRC may include surgery, chemotherapy and or radiotherapy. Most people survive.
  • In a typical group of people treated for CRC a large proportion will develop long term side effects.
  • After treatment most patients will attend a specialist clinic briefly once a year, they will have unmet needs.
  • All patients will visit their GP/Family physician/Primary Care Practitioner more often than that mainly about their other problems.
  • We know the sorts of problems they present to their GP.
  • We also know that there are many problems or concerns that the patient does not voice to their GP and that treatment for CRC diminishes quality of life.
  • Primary Care Practitioners have the skills and resources to help people in these circumstances although they might need some additional guidance.
  • [We need a tool to help patients focus on these side effects and help them present this information to their GP.]
  • We need a tool that does not require fundamental reform of the healthcare system.

[A team of PhD students is working to fill in the blanks- their expertise will give us the capacity to focus on other such conditions]
In developing this program for innovation they worked with people who have been closely affected by this condition. They worked quickly, economically, creatively and in partnership with the healthcare practitioners involved in responding to the needs of patients and their families. Their work is beginning to be published.

Innovating for multimorbidity

Most people who consult doctors in primary care have more than one problem. The proportion of people with so called multimorbidity is set to rise exponentially as the proportion of older people in many countries rises. The problem is that the length of consultations is limited and therefore the patient and practitioner are already at a disadvantage before they begin. Do you focus on the rash which the patient is anxious about today and which may be the beginnings of eczema, or the hypertension which isn’t at target despite therapy, how about the cigarette smoking and the aching hip and to what extent does the chemotherapy treatment in the past have a bearing on the fatigue that the patient has complained about in the previous consultation. In theory consultations can be extended for patient with greater need, assuming that the need is expressed. According to one team:

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician.

Bell et al JAMA 2001

The bottom line is that there is significant unmet need. In theory, in many countries the general practitioner has a longitudinal relationship with the patient and will eventually get around to some of these other issues.  Even in those countries that espouse the concept of  primary care as the first point of contact for people with the healthcare system, the reality is that people tend to consult more than one GP, either by choice or because they have no option and therefore continuity of care is theoretically possible but never actually achieved. The consequences include poor outcomes. It’s even worse in the specialist sector where regular turn over of junior staff means that people seldom see the same doctor from visit to visit.

Here is an opportunity for lean innovators to proactively screen people with a specific problem- for example all patients who have been treated for cancer attending a practice or by offering people an opportunity to have their needs met in another way– either by empowering self care or by enlisting the support of a nurse or allied health care provider. People in distress who are in contact with healthcare organisations cannot be left to fend for themselves or allowed to live under the impression that a diminished quality of life is the best that is now on offer.

Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

Integrating primary care providers

People can, and do, consult other than doctors when they are unwell or perceive that there is something the matter with them. The list is large but includes:

  • Pharmacists
  • Nurses
  • Podiotrists
  • Dentists
  • Physiotherapists
  • Opticians

These care providers offer  a specific skill set but this does not include the ability to deal with undifferentiated conditions or to make a definitive diagnosis of a condition outside their scope of practice. However research suggests that such primary care professionals are often among the first to treat someone with depression, cancer, atheromatous vascular disease, hypertension and or dementia. Early diagnosis and treatment of any of these conditions would result in a much better outcome for patients. That does not mean that these health care professionals could or should be a substitute for medical practitioners. For one thing their business model does not allow them to spend time on dealing with the complexities that are inherent in establishing a diagnosis of such conditions, or to deal with the many others that need to be ruled out in the differential diagnosis. Nor are they equipped to coordinate the care of people with such conditions.

Cheap intuitive and creative solutions include ways to signpost people who present with such problems to the care professional best placed to coordinate their care. Research suggests that when someone is offered a note to present to a medical practitioner suggesting investigations for significant pathology, people will follow up with an appointment and benefit. The components of such an innovation include a way to screen people for risk of significant pathology- the person with persistent diarrhoea seeking advice from a pharmacist, the person with unrelenting back pain who might be clinically depressed, the person with undiagnosed diabetes presenting with visual problems. All these people need to consult a medical practitioner. However they are not always recognised and here lies the scope for relatively cheap innovation to integrate care providers without interfering in the way care providers function within their own domain of expertise.

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

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.

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?