Clinical innovations - Rise of Innovation-Driven Care

Physician Innovations as Positive, Collaborative, and Achievable Engines for Reform

* Planned presentation before Innovators Conference, Heberman Center, Magee-Womans Hospital, University of Pittsburgh Medical Center, November 9, 2007. Not delivered because of death in author’s family.

Thank you for that generous introduction, which I so richly deserve but so seldom get. Thank you too – Doctor Anthony DeGoioia, the inspiration for this conference, AMD3 Education and Research Foundation, the Innovation Center of Magee-Womens Hospital of the University of Pittsburgh Medical Center, and Blue Belt Technologies, a technology development firm here in Pittsburgh.

My theme today is,

Nothing achievable, practical, or sustainable will occur in health reform unless physicians participate and actively collaborate.

My creed is,

innovations showing American physician ingenuity at its best are our best chance for positive health system reform – better, cheaper, more convenient care;

physicians can best initiate and carry out these innovations by collaborating with hospitals, other health care institutions, and the business community;

innovations most achievable are an extension of our present knowledge base using existing human and institutional resources.

Sophisticated Audience

You’re a sophisticated group. I will not fog any fastballs by you or bewilder you with softballs. The real world has hardened you. Your members include entrepreneurs, innovators, movers, shakers, venture capitalists, information technologists, biomedical engineers, hospital executives, business leaders, and physicians, all bent on innovating.

Keys to Innovation Success

What makes innovations tick?

The keys to successful innovation are:

• Experienced entrepreneurs, often physicians, armed with concepts that make a difference, and management teams that takes those concepts to market.

• Usually local, but increasingly national and even international venture capitalists, with the resources to convert concepts into achievable realities.

• Incubator cities with commercially successful business enterprises, financial resources, established medical institutions, and academic and business feeders of talent, all possessing the requisite skills in a critical enough mass to make innovations work.

• Markets to support innovation. No innovation is worth a damn, unless it advances care, .doesn’t burn cash too quickly, and supports the management team, the talent required , and mounts marketing effort needed.

Supportive Environments

We all know the legendary supportive urban and regional environments. These environments exist in every major U.S. city over a million inhabitants where critical talents and resources meet.

Nashville, HCA, heart of the for-profit hospital industry, which has spawned over 300 health care companies in Nashville and environs.

Boston, Route 128, to which innumerable health enterprises, many venture capital firms, a number of leading academic medical centers, the Massachusetts Institute of Technology, and the Harvard Business School contribute.

Minneapolis, Medical Alley, home of Mayo, the University of Minnesota Medical School, Medtronic, St. Judes, The United Health Group, and more than 800 licensed medical device dealers.

Pittsburgh, this Innovation Center, the University of Pittsburgh Medical Center, Carnegie Mellon, to mention a few, and others. You know what makes this great city tick as a an engine of medical innovation.

Other supportive innovation environments include: Seattle, Microsoft; Silicon Valley; Google, et al; Baltimore-Washington, D.C (Darkness and Confusion), Johns Hopkins, Revolution Health; The NYC medical industrial complex, Chicago, Austin, other Texas cities, and a host of other cities.

A Word about Orthopedic Surgeons

Just a word, if I may, about innovation and orthopedic surgeons. About fifteen years ago, I gave the keynote address before the American Academy of Orthopaedic Surgeons in San Francisco. Afterwards, the president of the association, a medical school classmate from Duke, toured me around the exhibit area. .I thought I was at a hardware convention – braces, splints, screws, nails, metallic inserts, hinges, rods, surgical saws – every imaginable device.

Ever since, I’ve said, “You can never tell what an orthopedic surgeon will do when left to his own devices.” And that preceded the boom in knee and hip implants, and other joint devices. I have a chapter in my book “Total Knee Replacement: An Innovator’s Dream,” which includes a bad pun, namely, that every orthopedic surgical innovator knows what Knees to be done. Now, of course, you’ve progressed to partial knees and robotic surgery. If, in this talk, I make any disjointed, displaced, fragmented, or miscast statements, I ‘m sure orthopedic surgeons in the audience will bring me into alignment. P.S. cardiovascular specialists are equally adept at device-development.

Hitting Nails on the Head

Speaking of hardware, I’m reminded of a phrase in The Golden Book of Writing, by a Dartmouth Professor, David Lambuth. He wrote, memorably, “If you have a nail to hit, hit it on the head.”

Today I shall hit these nails on the head., I shall speak,

• of what it takes for successful innovations;

• about the rise of innovation care as the salvation and heart of American health system;.

• of examples of what I consider major innovations;

• of 28 innovations heralded by Health Affairs, Wall Street Journal, and Cleveland Clinic.

• of what lies ahead.

Rise of Innovation

Innovation and entrepreneurship lie at the heart of the U.S. economy and of Western Capitalism. These twin concepts separate U.S. from other nations, and largely account for our robust economy, a theme articulated by Peter F. Drucker in Innovation and Entrepreneurship (Harper, 1986). Even today, even given the rise of globalization and the entrepreneurial Asian tigers,

• Most major innovations still come from U.S. This is changing with globalization and Internet, as evidenced by the sharp spike in collaborative innovation ventures with European and Asian companies

• innovation conferences, including this one, and Innovation Institutes, Innovation Congresses, and Innovation Summits are sprouting everywhere;

• emergence of CIOs (Chief Innovation Officers) as co-equal members of “C-suite, ” the new big thing in American hospitals.

• obsession with new ways to create a constant stream of new innovation ideas.. “Wild idea teams,” are blooming as keys to survival and thrival;

• explosive growth of alternative sites of care – retail clinics, urgent clinics, cash clinics, ambulatory centers of care, surgical hospitals, worksite clinics, and homes themselves – all falling until the rubric of “convenience care sites.”


• sudden entries into the health care technological arena of the IT Big Dogs, Microsoft, Google, WebMD, and countless other mid and large technological tigers with a Health 2.0 agenda. This agenda includes the aggregation and interdigitation of PHR, EMRs, Claims, Health Management, and Vendor Management Data – with data dumping into a common data repository guided by algorithms.

• movements towards more private and personal care settings –concierge and retainer practices, and home care is taking place.

Not All Innovations Are Technological

Not all innovations are technological. Health reform is not primarily technological, though all politicians are pushing information technologies as the underlying key to success. Many innovations are cultural, sociol, organizational, physician-developed, or market-driven products reflecting desire for reform, safety, quality, greater economic and clinical convenience, freedom, and choice.

• New practice sites, retail and workplace clinics, for privacy, convenience, and lower prices.

• New methods of payment, including an active credit industry, for elective, life style-enhancing and even life-saving procedures

• New organization models, Big MACCs (Multispecialty ambulatory care centers) removed from hospital campuses and situated in suburban, exurban, regional, and retirement communities


• New practice designs – concierge, cash, retail, urgency care, disease specific integrated ventures, group care

• New forms of marketing and patient engagement – kiosks, internet-based user groups, medical shopping complexes.

A Little Background as to My Qualifications

I’m a pathologist, I’ve watching these events for the last 35 years through conversations in hospital staff rooms, medical meetings, and front-row seat in operating rooms and differential diagnosis sessions. I founded the National Association of Physician Hospital Organizations, now defunct because PHOs became known to doctors as HPOs, i.e. run by hospitals for their benefit, not the benefit of physicians. For the last 11 years, I’ve been editor-in chief of Physician Practice Options, a monthly newsletter designed to promote efficient doctor practices. I’m author of Innovation-Driven Health Care, 34 Keys to Transformation (Jones and Bartlett, 2007), now used in many MHA and MD/MBA programs. I’m a blogger. www.medinnovationblog.blogpot.com, My blog now has 340 daily entries. Lastly, I’m on the Medical Advisory Board, America’s Top Doctors, which, through a complicated process of peer approval and peer questions, picks the top specialists in America, most of whom practice in academic settings.

Lastly, and perhaps most important, I’ve had a personal interest in these innovation projects.

-- developing a differential diagnosis program based on 700 abnormal lab results in early days of Internet,

--creating 150 bundled bills combining hospital and specialty fees for hospital-based procedures,

-- following closely the launch of medicalhistory.com Emmi.com, Sermo.com and SHAPE Medical Systems.

Out of These Activities

Out of these activities has come,

This personal bias: Physicians often make best “early” medical entrepreneurs and innovators. They know physician and public mindsets and unfilled medical niches. “Innovation is easy. Find the niches – and reward the sons of niches, ”

And this huge caveat: To ensure the success of any innovative physician enterprise, physicians need help (and lots of it) in writing business plans, forming management teams, seeking venture capital, taking products to market, and knowing when to step down once innovation is launched

Examples of Innovations with Which I Have Personal Experience

Bundled Bills for Hospital-Medical Staff Procedures, Oklahoma City, while serving as a PHO chairman

Emmi Solutions online interactive “expectation” programs for patients about to undergo surgery – in current use at U. of Pittsburgh Medical System

Sermo.com for free-wheeling dialogue between physicians

SHAPE (Superior Hospital and Pulmonary Evaluation, Mayo Clinic

Bundled Hospital-Physician Bills for Hospital Procedures, Oklahoma City

This is a powerful because consumer-driven health care will demand it or some variation in the future and because it requires close collaboration between physicians and hospitals.

Market demands will include:

• Transparency in advance

• Close collaboration between hospitals and doctors

• Predictability backed by reinsurance

• Efficiency, convenience, ease of access for consumers

• Inevitability because of ability of IT data mining and predictive modeling to predict costs of “episodes of care”

• Need for hospitals and doctors to co-exist in Medical Arms Races and to differentiate themselves from rivals.

Emmi Solutions, Chicago, Illinois

This is powerful because it brings together and entails practical collaboration between – hospitals, physicians, and patients – and benefits all of them by bringing greater safety, efficiency, understanding, and lower malpractice risks.

• Doctor inspired. Chicago-Based

• Online Patient Accessible, Internet Programs

• Verbal, Visual, and Interactive Features

• Hospital Financed

• Doctor “Prescribed”

• Addresses and overcomes cultural Illiteracy

• Engages patients on their own level

• Prepares patients and meets their expectations

• Reduces malpractice exposure

Sermo.com, Cambridge, Massachusetts

This is powerful because its sets up an easily accessible discussion forum for practicing physicians, and in the process, shows their concerns, biases, thinking patterns, trends, inclinations, and disinclinations. Whether our critics like it or not, physicians are the driving engines of innovation and reform, and their input and collaboration will be required to achievable reforms.

• Physician founder and CEO

• For licensed doctors only

• Free-wheeling discussion site

• Backed by Wall Street firms and AMA

• Focuses on doctor trends. attitudes, and beahivors

• Doctors driving force for 80% of spending

• Revealing pros and dons of marketing innovations directed towards practicing doctors.

SHAPE Medical Systems, Inc, St. Paul, Minnesota

This is powerful because it used tested and proven methodologies, addresses two of the leading causes of death in America, detects them early through physiological tests, and is portable, affordable, and useable in multiple settings – inside and outside physician offices. It builds on the past and will be achievable in the future and rests on the solid collaboration with a major institution.

• Fifth generation – 50 years of heart and lung physiological testing

• Less expensive, smaller, and less risky than traditional coronary treadmill

• Tests heart and lung function simultaneously and early

• Predictive modeling – risks of hospitalization and death

• Lends itself to testing for multiple testing situations and in multiple settings

• Validated by Mayo Clinic

Lists of 28 Innovations

First, Health Affairs

1. MRI and CT

2. ACE and angiotensin inhibitors

3. Balloon angioplasty with stents

4. Statins

Mammography

6. CABG

7. Proton Pump Inhibitors and H2 Blockers

8. SSRIs

9. Cataract extractions,. Lens implant

10.Hip and knee replacement.

Wall Street Journal List

1. Tekturna, anti-hypertensive drug, Novartis/Speedel

2. Technology for single test to identify infectious organisms, Genaco Biomedical products

3. Elaprase, Rx for Hunter’s syndrome

4. Humira, injectable Rx for Chrohn;s disease

5. Noxzfil, Rx for life-threatening fungal disease

6. Eclipse – Portable 17 pound unit carrying
concentrated O2 for victims of lung disease

7. Upright MRI, Fonar

8. Titanium device for Rxing lumbar stenosis symptoms

Cleveland Clinic List

1. Flexible intralumenal robotics

2. Percutaneous aortic valves

3. RNA therapeutics to reduce LDL and triglycerides

4. Genomic screening for health assessement

5. New drugs for clotting and bleeding control

6. Nasal administration of flu vaccine to infants

7. Image fusion for dxing and guiding minimally invasive procedures

8. Implanted devices to restore movement

9. Engineered cartilage for joint repair

10. Dual energy source for CT to reduce radiation exposure

General Spheres of Future Major Innovations

1. Consumer-driven health care

2. Chronic disease management

3. Health care IT (particularly tools for consumers to better manage and pay for health care)

4. Public-private partnerships to manage care for seniors

5. Customized care centers (chains to deliver high quality, cost effective services locally, regionally ,and nationally.

6. Health 2.0 -This Data-Mongering, Mother, and Granddaddy of All Innovations , reformulates data for decision-support, transparency, and revitalized health care markets. It consists of expert content, data-based, artificial intelligence and predictive-modeling algorithms for better decision-making for patients, clinicians, health managers, and purchasers.

Whether Health 2.0 represents hype or reality is not known at present.

Close

I close with two thoughts on innovation.

1) The Internet is the greatest innovation ever to hit health care.

2) Data – no matter how innovatively manipulated or how artificial intelligence refines it or mines it – will ever define or dictate – the human experience with health care: it takes doctors, interacting intimately with patients – to do that.

Thank you.