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Applying Excellence by Design…for Healthcare

Much of my professional time over the last few months has been focused on the area of Healthcare and considering the application of Excellence by Design techniques to it.

Here’s a look at Healthcare using just some of the Excellence by Design model facets:

  • Environment: Challenging! The Healthcare industry is perhaps the leading example today of a challenging Environment that exhibits the paradox of Chaos vs Control.  (Control) The industry is facing unprecedented standardization and regulatory pressures driven by government entities.  These cover things like basic interoperability of protocols based on the National Information Exchange model (NEIM) in which the US will guide the development of a  health information exchange framework.  There is also new content standards for specifying clinical diagnosis and procedures, among others.  These new standards will/are significantly affecting the Environment that all players must live in, whether they be software product vendors, information value added services vendors, hospitals, insurance carriers, or others.  (Chaos) Of course at the same time the desire to drive new competitive innovations marches on, in medical devices, in information (i.e. business) intelligence services, and in solutions that drive cost down and effectiveness up.  But don’t forget that many/most Healthcare systems are based on pretty antiquated technology.  So all this change is occurring against a landscape that badly needs modernization of basic infrastructure.  From my perspective it seems the Healthcare industry, which has been a laggard in IT evolution compared to other industries (in particular Manufacturing, Finance, and Travel) in both optimization (Control) and innovation (Chaos), now seems to be paying the piper by having to face simultaneous pressures from multiple directions, in a shorter (government imposed, politically energized) timeframe.
  • Systems as Strategy: A Paradox. A key facet of Excellence by Design is the use of ‘systems as strategy’ (meaning structured approaches to problems and design of systemic solutions to them).  The Healthcare industry has a dual personality it seems in this regard.  The medical/clinical side of the industry is the poster child for developing structured approaches to disease discovery, diagnosis, and treatment.  It is a hallmark of the industry.  Yet IT has not adopted this same level of rigor.  Why?  Typical reasons given are underinvestment in IT in general, relatively low competency (in staff and even in CIO roles, which are being posted with a flourish these days, as if it never was regarded as important before!) a lack of cross-industry driven desire to solve some of the broader IT challenges like Automotive did with CAD and Supply Chain, or like Finance took on with bank funds transfer interoperability and stock trading processing.  The Healthcare industry and its functional organizations have generally tended to remain ‘islands’ that did not seek to cooperate among competing entities, technology providers, and even across functions within a company.  There was with little application of broad ‘systems’ of execution as a strategic approach to business process design and technology solutions planning.
  • Product as Platforms: An Opportunity (again). As an industry, the IT solutions employed for Healthcare are very ‘siloed’ both in design and in implementation.  Other industries have shown the advantages of greater integration of IT solutions into broad platforms that enable a wider class of functionality and information insight, in a more consistent and approachable (same UI, same interface, etc.) form.  Of course the classic examples are the ERP vendors, although their offerings have become so bloated and complex they are not the model I would recommend.  Better examples are Salesforce.com, Amazon, and e-Bay.  These have become very successful not only due to their function and content, but because of the capability to provide as ‘platforms’ that are extendable.   Other companies are following this trend.  Facebook and Twitter are among the many social networking offerings that are trying to grow beyond being ‘an app’ to become a ‘platform’.  So what is happening in Healthcare?  Not clear yet.  While there is some noise in this direction I cannot say I have been overly impressed that what I have seen is more than marketing spin.  Just adding function to an existing offering, or rebranding/bundling of applications, does not a platform make.  In my forthcoming book (or a future blog post) I’ll provide some general characteristics that I believe define a great product-as-platform.

In summary, Healthcare is either a scary place to be, or the best game to be in right now.  The industry is facing great change, ripe for all kinds of improvement, forced with a sense of urgency by government, and has a noble mission to improve the lives of people.  It can be a great podium for those wise and skilled enough to apply smart approaches to meet the challenge. It can also be a vast graveyard for the those who are unable to think broadly, and try and save the patient by applying the ‘one more band-aid and pray’ approach.

I am optimistic that, driven by the forces of today, the industry (and IT especially) will leverage the good capabilities that abound, to improve efficiency of operations, as well patient outcomes.  But of course I also believe a key to most effectively doing this is not brute force but Excellence by Design.

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‘Optimizing versus Innovative’ Excellence by Design

The words ‘Optimization’ and ‘Innovation’ can spark an interesting debate.  They are related of course, optimization sometimes requiring an innovative idea or approach, and innovation often including optimizing elements.

But if we widen the gap between the two to see what ramifications to design it may have, I would offer the following:

In the IT world today there is a growing difference between what one might call ‘optimization’ and ‘innovation’.

Herein I define the following:

  • Optimization as being focused on doing the same things better but in the end, providing the same type of service.
  • Innovation on the other end is primarily focused on (or most obviously innovative) when it results in a new type of service, even if it (almost always) includes some existing capabilities.

Another words, while inventions occur in both, one is improving an existing service/capability, while the other is delivering a (very) different, new service/capability.

What does this mean from an Excellence by Design point of view?

Optimizing:

Continuous process improvement, technology refreshes, and adding/upgrading capabilities in infrastructure are good examples of optimizing. Other examples are adding servers, or server virtualization, or developing a new portal, or launching a new, more functional ERP solution. The list could go on…

A more valuable optimizing example occurred during my experience at Ford. We made major progress by emphasizing that the design of new infrastructure include a holistic view on the technology, the integration, deployment tasks, maintenance/upgrades, and even the planning process for next revisions. We called this particular activity the ‘pattern engineering process’ and it was and still is an effective, holistic approach to Excellence by Design when optimizing IT infrastructure services. This work laid the groundwork for what we called ‘utility computing’ back in 2002.  We were visionaries apparently because this is what Nicholas Carr wrote implied in 2004 when he asked Does IT Matter and in 2008 in his book The Big Switch.

I say optimizing because while there were lots of new things about the Pattern Engineering Process approach, we still were generally, providing similar services at the end of the day, not a radically new and different (e.g. what I refer here to as innovative) type of service. We were just trying to optimize it to a utility as reliable as the electric utility is today.

It’s interesting to note the type of consideration that rise to the Designers attention when in this more ‘optimizing’ mode: Improving quality, repeatability, consistency, and continuous improvement as measured by metrics of focus such as cost, time to deploy, availability, etc. usually through use of existing technology, and reuse of best practices. In essence, the designer is trying to integratively pull together the best of the best of what is known and possible, to achieve an optimized end result.

==> My point here is that 1) Excellence in Optimizing is a large opportunity and thus a very important, very valuable capability for a business to have, and 2)  it has its own particular design aspects to be considered and 3) it can have transformational effects, as the shift from building IT infrastructure has transformed from one-in-a-row, to repeatable process, and now to ‘cloud’ computing.

The moral of the story here is that an excellent organization understands this near term value and potential long term transformational effects, and ensures it has some focus on and competence in this.  My personal experience is that most companies really don’t apply rigor and expertise to optimizing opportunities.  They prefer to ‘ask’ for the results (less cost, faster cycle time, better quality, etc.) but do not invest formally in the design skills/capabilities to excel in optimization.  There are many exceptions but they are generally in the manufacturing (and sometimes the engineering) function.  It is much rare to see any real focus on optimization in HR, or Marketing, or Finance.  IT is usually somewhere between this spectrum, with most of the optimization being either assumed to come from new technology, or more rigorous project management.

Innovation:

While the word ‘innovation’ can include all sorts of improvements, large and small, lets consider that innovation which intends on producing a new (the more radical, the more innovative) type of service.  To a greater extreme, lets consider strategic innovation, that is intended to produce a transformational effect.  A nice book to use to get thinking about things this way is Pull, by David Seigel.  The book has really only two points, one relatively boring, one that can drive quite innovative thinking (and design). The first is his discussion of the so called ‘Semantic Web’ (which basically implies that if everything was just organized (namespace, categorization, even meaning), then computing power can be applied to deliver radically improved results/insights/efficiency.  Frankly this is not real news to anyone who has spent much time in IT, but if you have not, than that element of the book could be very enlightening to you.  the second point is the more radical from an innovative design perspective.  David projects (and I completely agree) that the technology world (web powered) is moving away from designing (whether optimizing or innovating) solutions that pull data and keep it in corporate databases.  The future is the ‘pull’ model where individuals and their data is the focal point, and business solutions are designed to pull this data (or data from other businesses) on demand.  This is not the only type of inovation, but its an interesting one to use for the example below.

The perfect example?

The health care industry is a perfect foil for projecting this.  They have generally been way behind in IT (in almost all dimensions).  Everybody knows it.  Now they face multiple forces fom cost pressures to new regulation to insurance carriers pressure to any aging population, etc.

So what is one big challenge you hear about today from an IT perspective? ERM: electronic medical records.  Is this innovation…uh, No. It is the industry catching up with the kind of data capture/retention that the manufacturing industry and the finance industry has had for more than 20 years.  It is optimization in the sense that this has all been done before, the service (capture the data, store it a database, so we can relate it and report it) is old hat.

But let’s turn it around.  Who is working on the idea of creating a health management system FOR THE PATIENT!  Now that would be innovative.  In fact I have been speaking with a large number of people about this…here is the vision and it’s innovations:

  1. In the future, a person will have a place to consolidate all their health information.  Not provided by a hospital or insurance carrier. More like a facebook app than a database, this service will allow information to be ‘connected with’ the person (just like you can link to a friend on facebook).  this information will include
  2. It will include data from your body.  Rather than the myriad of proprietary devices used today to measure heart rate, oxygen levels, etc., biomedical engineering and IT standards will come together to allow you (or your Dr.) to apply ‘bandaid-like’ monitors to your body, which will transmit data wirelessly to a standard device (probably an iphone) you carry.  This web of data, transmitted over standard protocols, will be a leap forward compared to the ridiculously custom and proprietary (and kludgy) ways of collecting data form a patient today.  It will be so easy it can be used whether you are a hyper athlete or a bed ridden critical care patient in the ER.  Standards do that, connectivity enables it.
  3. It will enable secure sharing with your trust network over the web.  Your Doctor can see some of your vitals.  Your caregiver can see if you have take your medicines. Your family (children who may live many miles away but want to keep tabs on their elderly parent) can see how you are doing, when your next dr. appointment is, last remarks/recommendations for the caregiver, etc.)
  4. Video conversations replace physical visits.   father spent 2 hours just yesterday waiting for what turned out to be a 7 minutes conversation with his Dr. about next steps in his cancer care.  This happens ALL THE TIME. This will be replaced with a video cam conversation, in which the Dr. can view online all your vitals, and occurs when the parties are free…fewer waiting room visits.  It will not replace situations where the Dr. must perform a physical inspection, but it can replace many calls, at far less cost, much higher convenience, and with the real time (and historical) data available, with more information of value to the Dr.
  5. Not a PC…a tablet.  yes this will all be accessed by the patient using a simple tablet, most probably the iPad or some competitive version of it.  Simple, highly functional and capable, it will become the ‘Crackberry’ of health management.  Just as business users felt isolated with their Blackberry, so will people feel without their ‘healthpad’ that has all their information from pills to take, appointments to make, and trusted partners available to call (video or voice) in an emergency.
  6. There is MUCH more.  I have only scratched the surface of what a designer must consider and could provide.  Discharge instructions, rehab assistance, performance training recommendations (for athletes), food intake management, high school athlete training programs…the list goes on.

So compare the ‘ERM frenzy’ with the vision above.  Both are important, both should be done with excellence, but the designers challenge is quite different.  The first (ERM) is a classic optimizing problem, using largely existing capabilities (even if they come from other industries) to produce a service that is largely understood (records mgt), has been done before (in many industries), for a typical audience (the hospital’s administration), in a typical way (I hate to say it but probably an almost mainframe like query and report UI, ugh).

The second is much different and highly innovative.  It requires designing from a very different perspective (the patient), developing new ways of gathering information and managing it securely, integrating a wide variety of function into a package (the ipad and the software experience) for the user that is more like a game, than a data entry/reporting application, and whose event model is based on ‘pulling’ data rather than pushing it.

Conclusion

When thinking about ‘Excellence by Design’ another important perspective is to consider whether your focus is primarily to optimize or innovate.  It may help you consider the options and best approaches in a better light.

P.S. If you are wondering what the Ironman image is doing in this post, it is because it is the  internal code name for a project I have been working on described above as the health management system for the patient, and as an Ironman series itself its a great example of optimization and innovation.