Fixing Health Care from the Inside, Part One
By Richard L. Reece, M.D. (August, 2008)

Lyle Berkowitz, M.D., a practicing physician, applies innovative thinking and information technology to health care conundrums.
 
Efforts to improve quality of care and reduce expenses won’t succeed without a healthy dose of innovation. Lyle Berkowitz, M.D., a practicing primary care physician at Northwestern Memorial Physicians Group, Chicago, has made a study of health care innovation centers and now leads the nonprofit Szollosi Healthcare Innovation Program (SHIP). In the first installment of a two-part interview, he discusses the need for reengineering across the health care continuum, and how to support and encourage innovation. Next week, Berkowitz explains SHIP’s mission and initial projects.

Richard L. Reece: Given your biomedical engineering background and your past work in software development and strategic consulting, how could health care benefit from reengineering?
Lyle Berkowitz: There are three interrelated areas that need major reengineering: how we take care of patients, how we reimburse physicians, and how we design and use electronic medical record systems.
First, good engineering means good efficiency and effectiveness. We need to recognize that we don’t have a shortage of physicians in America’s health care system; rather, we are not using physicians efficiently and effectively. Our current system is built on the premise that all care must be done via face-to-face visits between a patient and a doctor. The result is a system where a single primary care physician is limited to a patient panel of about 2,000 and is often rushed in visits with them.
We therefore have to shift our paradigm to think about how we can most efficiently and effectively use each of the providers in the health care environment, including physicians, nurse practitioners, nurses, medical assistants, physical therapists and social workers. A good model to explore is the advanced medical home concept, in which a primary care physician serves as leader or manager of a team of providers.
Consider the scenario where a primary care physician manages a team that provides both onsite and “virtual” care to a large patient population. In the office, a variety of physician extenders armed with evidence-based protocols could provide routine care for uncomplicated cases, such as colds, urinary tract infections and stable diabetics. As a result, a physician could spend more time with those patients who have more serious or complicated illnesses. And if some of the routine care could be performed virtually via the phone or Web, this system could combine the effectiveness of evidence-based medicine with the efficiency of non-office-based care. In fact, this type of model is already successfully employed by some West Coast organizations in capitated situations.
However, to make this model successful for the rest of America, we need a reimbursement system based on how well this type of medical team could care for a large patient population, regardless of the method of patient interaction. In other words, a system that rewards value over volume and rewards providers for how well they take care of patients, not how often they see them.
Finally, this type of model also requires an EMR system optimized to support protocol-based care, population health management and delivery of virtual care via the phone or Web. And, it must do so in an intuitive and cost-effective manner.
I’m not the first person to talk about the need to reengineer the system. For example, one of my innovator idols is Larry Weed, M.D., the inventor of the SOAP note format. Back in 1968, he said, “It will be necessary to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel, and a more positive attitude about the computer in medicine.”
That was 40 years ago, and he was spot-on, and yet we have not come very far. Unfortunately, there are plenty of cultural, technical and financial barriers making these transitions difficult. The good news is that providers, payors and patients all share the same goals of high quality and efficient care for all. Therefore, it should be no surprise that we are seeing the rise of a variety of innovation centers across the nation, which are starting to create new processes and tools to improve efficiency and quality, while also testing new models of care and reimbursement. We need to make sure these innovations are funded and supported, because the result will be a higher level of care that benefits everyone.
Reece: How can health care providers and leaders support innovation?
Berkowitz: Innovation in health care has traditionally focused on devices and medications. The result has been the rise of CT and MRI scans, implantable devices of all sorts, and an explosion of drugs for almost every condition.
Now we need to apply this same level of ingenuity and innovative thinking to process improvement. Fortunately, more institutions are doing great work, and we need to share our knowledge so that better ideas will keep bubbling up. For example, the Innovation Learning Network, led by Kaiser’s Innovation Consultancy, connects innovation centers to foster collaboration and promote the exchange of ideas. Meanwhile, the Agency for Healthcare Research and Quality has created the Health Care Innovations Exchange as an online forum to share innovative strategies and quality-related tools.
Innovation is not a spectator sport. We need to acknowledge that our current system has to improve, and we need physicians and others to get involved in making change happen—whether that is joining a process improvement committee or simply being open to a new idea when others present it. Be inspired by the fact that some of the best innovation comes from single individuals who simply see things a bit differently. Take comfort in knowing that trying and failing may still lead to success if it creates an ongoing discussion about the topic at hand. William J. Mayo, M.D., said, “It is better to think and sometimes think wrong than not to think at all.”
I encourage hospital leaders to set up small, independent innovation centers to experiment with improvements that could be made at their institutions and to learn as much from failures as from successes. I encourage physicians in small practices to devote at least an hour every month to figuring out how a certain workflow could be performed faster or better within their office or hospital. I hope that they will find that one hour invested could save them many more hours down the road.
Finally, believe in your ideas. If you can figure out a way to do something faster, cheaper and better, then share your knowledge. As Margaret Mead said, “Never believe that a few caring people can’t change the world. For, indeed, that’s all who ever have.”
Next week: Berkowitz discusses the Szollosi Healthcare Innovation Program and its initial IT projects.
Richard L. Reece, M.D., is a pathologist, author, editor and speaker. He is the author of 10 books, most recently Innovation-Driven Health Care: 34 Key Concepts for Transformation, and a blog.


Fixing Health Care from the Inside, Part Two
By Richard L. Reece, M.D.

Lyle Berkowitz, M.D., a practicing physician, leads an innovation center focused on improving health care for everyone involved.

This is the second installment of a two-part interview with Lyle Berkowitz, M.D., a primary care physician at Northwestern Memorial Physicians Group, Chicago, and leader of a health innovation center.
Richard L. Reece: Tell me about the Szollosi Healthcare Innovation Program.
Lyle Berkowitz: In January, we launched the Szollosi Healthcare Innovation Program (SHIP), a nonprofit organization with a mission to use creative thinking and diverse technologies to produce a better health care experience for patients, others associated with their care and physicians.
On a more concrete level, we intend to focus on real-world problems that have a significant impact on patients and physicians. Our plan is to create pragmatic solutions that are more efficient and consistent than the status quo and that can be used by all physicians regardless of their information technology infrastructure. Additionally, we plan to work with Northwestern University researchers to study these new tools and workflows. Finally, we hope to distribute any successful ideas and tools outside our own organization.
We started this program by researching the topic of innovation in health care. This included talking to a variety of researchers at Northwestern and then studying some of the well-known health care innovation centers in America, including programs at Kaiser Permanente, Group Health, Johns Hopkins, Partners HealthCare, Geisinger Health System and the University of Pittsburgh Medical Center. Additionally, we studied a variety of other organizations, such as Virginia Mason Medical Center, the California HealthCare Foundation and the Institute for Healthcare Improvement. This research will be an ongoing part of what we do, but we are also planning to expand outside the health care sector and look at innovators in finance, publishing, travel and the arts—nothing will be off-limits.
Reece: How does SHIP differ from other innovation centers?
Berkowitz: First, our funding comes from philanthropic sources, so we have a bit more freedom compared to other innovation programs that are funded by their hospital organization or via research dollars.
Second, I have some unique biases as a practicing primary care physician running the program. For example, my main interest is in the outpatient realm and because I have to use any system we develop, I will be particularly attentive to creating very pragmatic and user-friendly solutions.
The third and perhaps biggest difference is that we are combining process improvement with product development, whereas most other centers reasonably focus on process change alone. While there is some risk, I believe there are three important benefits to this strategy. One is that by building simple, Web-based applications, we think we can improve adoption of new processes by making them easier, more consistent and more cost-effective to implement. The second is that we can freely or cheaply distribute any tools we develop.
The final benefit is the ability to really think creatively and develop highly specialized tools and processes that could not be created if we had to work within the constraints of standard EMR or paper-based systems. In fact, I believe there is a growing role for innovators to create niche products that lead to an immediate impact on patients while encouraging commercial vendors to build similar functionality into their products over time. Alternatively, we might see an iPhone-like future, where a company creates a standard platform upon which independent developers can build anything they want.
Reece: What are the philanthropic sources behind SHIP?
Berkowitz: Our program was created to honor the memory of Peter Szollosi, a creative director in Chicago who knew how to bring diverse people together and do things others didn’t even dream about. He had a mantra we stand by: “Don’t tell me what you can’t do.”
Peter was diagnosed with cancer in 2006 and had a variety of complicating factors that required him to see multiple specialists at Northwestern as well as seek out second opinions at a number of cancer centers nationally.
As his primary care physician, I saw Peter often and guided him through the system. We talked a great deal about how to improve communication and coordination among these physicians and health care organizations. Even though he was not a health care expert, Peter’s underlying creative drive was both inspiring and educational, and he encouraged me to try to solve the coordination and communication problems that he and other patients often faced.
Peter passed away in the fall of 2007 before we could take full advantage of his knowledge and experiences. To honor his memory and legacy, those who were closest to him decided to help carry out his intentions by funding the Szollosi Healthcare Innovation Program.
Reece: How does SHIP work?
Berkowitz: We have created a strategic model to identify problems, obtain buy-in from appropriate sponsors and develop real-world solutions that fulfill our mission of improving patient and physician experiences. Additionally, I am part of the largest primary care medical group in Chicago, and it has agreed to serve as the pilot site for the processes and tools we develop, thus making it easier to demonstrate success in the real world.
We focus our efforts around dealing with complex and critical medical issues, particularly in the outpatient environment. The result has been the identification of two solution themes: information sharing and information visualization.
Within the information sharing theme, we plan to create new workflows and tools to enable better communication and coordination between patients and physicians, as well as among physicians taking care of the same patient. This is especially important for complex patients who have multiple providers and are more likely to have critical and urgent issues.
Within the information visualization theme, we plan to develop ways to more easily view and understand the massive amounts of information presented to both patients and physicians. Our initial goal will be to develop prototypes of what EMRs could look and act like in the future.
Reece: What projects has SHIP undertaken since its inception?
Berkowitz: Our first project, ExpectED, has been in beta-testing since April 2008. It is a Web-based tool that allows a physician to notify the emergency department about an incoming patient. The physician fills out an online form which then prints at the ED triage desk for use when the patient arrives. Lessons learned from this project are already being used in a bigger project involving computerization of the whole ED system.
Our second project, the Inflection Navigator, combines the idea of health advocates with a Web-based registry empowered by issue-specific protocols. These protocols will focus on coordination of care in the midst of acute inflection points in a patient’s health, such as receiving a diagnosis of cancer. The vision is for this to allow for a concierge-like level of care for patients who really need it but do so in a cost-effective manner by focusing only on the area of highest need and by ensuring the most efficient use of both human and technical resources.
Reece: Tell me about your plan to improve user interfaces for EMRs and patient portals.
Berkowitz: One of the main complaints about EMR systems is that they are not easy or intuitive for physicians to use, which can lead to inefficiencies and problems with quality of care. We want to develop prototypes for a wide range of user interfaces to better support the real-world needs of care providers. We plan to explore the fields of information visualization and video gaming to come up with ideas that are both unique and useful. We hope that these prototypes will encourage commercial vendors and others to think about how they might evolve their systems. We plan to have initial prototypes released by the end of 2008 and available on our Web site.

Richard L. Reece, M.D., is a pathologist, author, editor and speaker. He is the author of 10 books, most recently Innovation-Driven Health Care: 34 Key Concepts for Transformation, and a blog.
For more information about the Szollosi Healthcare Innovation Program go to www.TheShipHome.org.

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