Rouse on Transformation

A recent issue of The Economist provided an in-depth review of how high technology financial startups are poaching high-margin financial services from large banks.  The large banks are not standing still; they are often acquiring these startups once they prove viable.  This may keep them in the game, but high margins are being substantially eroded for services that were once cash cows.

There have been many related discussions in the vehicle industry.  Many vehicle manufacturers are trying to position their vehicles as service platforms.  OnStar by GM is a classic example.  As more high-tech vehicle services emerge, it may be that Apple and Google, for example, will be the innovators rather traditional automobile companies.  They won’t produce the cars, but they will make the profits.

Both of these examples involve industries with business models, especially cost structures, which overprice technological innovations, yielding profit margins that can compensate for enormous inefficiencies elsewhere throughout their enterprises.  In general, disruptive technology-based innovations can obsolete business models and displace mainstream providers who are deluded by the incumbency of their traditional approaches to their markets.

There is a significant opportunity to disrupt the business models of consulting service companies that provide business process improvement services to healthcare providers.  The disruption will completely undermine the construct of the “billable hour” for these services.  Consider these observations:

• Healthcare providers are notoriously inefficient users of capacities, in part because they get paid for everything they do regardless of relevance or efficiency.  Any reasonably competent process engineer can see countless low hanging fruit in terms of process improvements.
• All major healthcare providers are delivering the same services, i.e., caring for the same maladies of humans ranging from hypertension, diabetes, and heart disease to automobile accidents and gunshot wounds.  There is no inherent reason that they could not all provide these services in the same ways.
• Such standardization has led to major efficiencies and increased effectiveness for sales force automation, logistics, supply chain, and inventory management, and numerous other industrial processes.  Healthcare delivery is ripe for such process innovations.

It is important to differentiate process innovations that involve direct adoption of, for example, logistics, supply chain, and inventory management, from those innovations that address healthcare delivery specifically.  The latter must draw upon evidence-based medicine to devise, evaluate, and generalize care processes for hypertension, diabetes, heart disease, etc.  Standardizing such services requires deep knowledge of diseases and procedures for screening patients, diagnosing disease states, and treating diseases.

One approach to standardizing care delivery processes has been to map the processes of each provider, leading to one-off solutions for each enterprise.  These process maps are used to identify process inefficiencies, redesign processes to eliminate inefficiencies, deploy new processes, and then evaluate both efficiency and effectiveness.  This usually requires an enormous number of consulting person-hours and, hence, is very expensive.

This approach is based on the idea that every provider is unique and, of course, every patient is unique, and only the knowledge and skills of their individual primary care physicians and specialists are adequate to know how best to treat an individual patient.  Such reasoning is deeply flawed.

The Institute of Medicine has found the following — from the time that a new best practice is proven until the majority of physicians have adopted the practice averages 17 years.  Other studies have shown that physicians’ approaches to care are much more affected by where they graduated from medical school than by research findings since they graduated.  Thus, most patients are not getting the best care.

To be fair, various thought leaders have shown that it is absolutely impossible for clinicians to keep up with the developments in their specialty.  They could spend all their time reading and still not be able to keep up.  The individual clinician, despite high motivation and commitment, simply cannot keep up with the generation of medical knowledge and delivery skills.

It might be argued that the medical literature provides all the knowledge needed to specify best practices.  However, the literature focuses on scientifically defensible knowledge rather than how to deploy this knowledge in the care delivery system.  The need to translate increasing knowledge to constantly improving best care practices presents an enormous business opportunity.

This opportunity is premised on the strong belief that there are definable best practices that every provider should follow.  These best practices can be identified and constantly updated.  Knowledge of these best practices can be deployed in terms of web-based interactive visualizations enabled by computational models that embody these practices.  Clinicians can interact with these visualizations, perform any desired “What if?” experiments, and assess the impact of updated best practices on health outcomes and financial consequences.

Once decision makers are convinced of the merits of the best care practices portrayed in the web-based interactive visualizations, it is inevitable that many will ask about how these practices can be customized to the demographics of their patient populations.  Much of this type of customization can be enabled online. Other types of customization, e.g., to their physical infrastructures, may be difficult to fully automate, at least initially.

The fully customized version of a provider’s processes and practices can be created and maintained online for their use in strategic and operational management.  Parameters within these processes and practices can be updated monthly.  Performance outcomes can be compared to predicted outcomes.  Deviations can be used to track down performance problems, for example, unusually long delays for out-patient diabetics.

The vision is to provide to medical practice what SAP provides to logistics, supply chain, and inventory management and Salesforce.com provides for sales force automation.  This will require a combination of compelling online capabilities with deep knowledge of medical practice, as well as an efficient and fine-tuned mechanism for constantly updating knowledge of the state of the art in medical practice.  In the process, the 17 years it takes to for the majority of clinicians to adopt best practices should be reduced to perhaps six months.  This will be a major contribution.