10 Tips on Hacking the Cathedral of Medicine
I had the good fortune of attending the first-ever Hacking Medicine conference at MIT. It was there that I first heard someone refer to hospitals as a kind of Cathedral of Medicine – both implying a false sanctity of how and what care is provided within the hallowed halls (i.e., the reverence for physicians in their priestly robes of white lab coats) and a kind of timelessness more indicative of stagnation than some enduring intrinsic value.
I don’t disagree with this analogy. However, I was struck by how few of the entrepreneurs and innovators had actually spent time working in hospitals or clinics. As the child of a physician and a nurse, and now as a web developer for a major healthcare system, I’ve spent much of my life around hospitals on both sides of the country. Here are my tips for hacking The Cathedral.
1. Start with Nurses
The nurses are the heart of any hospital. They have the inside track on every physician, every problem with facilities, every new initiative that’s come down from on high and how well it did or didn’t work with patients. If you want to find out the biggest areas of need, ask a nurse. If you have an idea, float it past a nurse. If you want a champion for a new technology, enlist the nurses. Not only are they a highly-skilled, technology-adept group to leverage for testing, they are also well organized (indeed, unionized in most places) and work in “units” that can function as pilot groups for new initiatives.
2. Money follows the specialist
Like it or not, the influence in a hospital is often held by those who bring in the most money. Keep in mind: Money is not always equal to patient volume. For example, most hospitals get a large chunk of their patients through Obstetrics and Gynecology. But maternity services don’t make any money for hospitals. If you’re thinking about initiative that might require a capital investment up front or might be a hard sell to hospitals for one reason or another, your better off pitching it first to service lines that bring in the big bucks. Often times the physicians that head up these areas also have significant influence over administrative decisions at the hospital. Think: Interventional Cardiology, Orthopedics, Neurology, and elective stuff like Plastics and Bariatric Surgery.
3. Beware of legacy systems
Hospitals have a lot of out-dated systems. They move slowly to replace them for a number of reasons, including the difficulty it takes to retrain users, the inability for a hospital to have any real “down time” on dependant systems, fear of untested technology, and a shortage of cash. For this reason, may hospitals take an “if it ain’t broke, don’t fix it” approach. Don’t be surprised if you work with a hospital and find out that you will need to have your application compatible with IE7 and no, IT has no plans to upgrade all browsers anytime soon. Which brings me to…
4. Tread carefully with IT
IT at a hospital has a tough job. Not only are they responsible for getting things like email and medication ordering systems running properly, they now have a slew of new regulations to contend with around patient privacy, electronic medical records and security. Because of this, working with IT can sometimes be frustrating, as they run any new initiatives through a myriad of bureaucratic channels. A few pointers:
- Do not try and cut them out of the loop. They’re going to have to bless any new project eventually. Might as well get them on board from the start.
- Do not assume that because you are a technology venture and have been invited to work with a hospital that IT is already at the table. You may be brought in via the web team, which isn’t always located within IT. A tech-savvy physician may have asked you to come and not run the idea past IT first.
- Not every hospital has an in-house IT staff. Many are staffed by vendors which have their own policies and procedures on top of the hospital’s own rules.
5. Its all about the beds
Hospitals measure their size by the number of beds they have. They calculate profitability by how full those beds are. They look for ways to improve how quickly beds are turned over and new patients fill them. Emergency rooms and triage areas get clogged because beds aren’t available. Beds are the site of patient care. Hospitals want patients to spend less and less time in these beds. Beds are the coin of the realm. Look for ways to tie ideas to beds or address issues hospitals have with filling, turning over, or reducing length of stay in beds.
6. Not all docs are on staff
Though the math on this is changing, hospitals in major metropolitan areas often have a mix of “voluntary” and “staff” physicians. Staff physicians receive a salary from the hospital and even if they maintain a separate office, their practice is often owned wholly or in part by the hospital. These physicians exclusively refer their patients to the hospital that hires them. The voluntary physicians are credentialed to admit patients to more than one hospital and they are in private practice. These physicians are often derisively referred to as “splitters” for having split loyalties to multiple hospitals. Obviously hospitals would prefer to promote those staff docs that will guarantee them the patients. However, no hospital wants to turn away the potential patients from a voluntary doc, because then you can be sure the business will be picked up by your competitor down the block. Thus, most hospitals have a mixed bag of physicians.
Here’s why this is a big deal for entrepreneurs:
A piece of legislation know as the Stark Laws prevent hospitals from favoring some docs over others. The laws also govern anything that might resemble a kick-back. So you can’t be seen as generating referrals for an organization in which you have a financial stake. Any technology that promises to drive more patient business to the physicians themselves needs to be aware of seeming to play favorites and how it incentives physicians to participate. In addition, you can’t pass down edicts to voluntaries in the same way you can do so for staff. So, want all docs to use your new app for taking bedside notes? Have a plan for how you are going to rope in the voluntaries. Don’t be surprised if there is no centralized way to communicate with all of them. Come up with a great new way to book appointments? Make sure bulk pricing makes sense because hospitals can’t pass the cost on to physicians if those physicians are salaried by the hospital. And remember…
7. There is a 90 day turn around on payment
Nope, we can’t get the check cut any faster. Nope, we don’t have a credit card we can use. Yes, you will need your contract reviewed annually before we can renew. Yes, IT will have to look at it again. Yes, we too find this frustrating.
8. Hospitals are reactive, not proactive
With a few rare and glimmering exceptions, hospitals are reactive, not proactive about their technology, for many of the reasons I mentioned in #3. Your best bet for introducing a new idea is to tie it to an existing problem. Hospitals don’t often respond well to the enticement to be the “first” to try our some new great product. They are slow and cautious about engaging with new technology. They respond better to peer pressure and will always ask you, “Well what other hospitals or healthcare systems doing?” Woe be to you if you try and offer up an example from outside the industry as a reference.
9. Remember that there is an art to care
In our rush to convert paper to digital, to gather metrics and crunch the data, it is easy to overlook the art in medicine. The best caregivers use evidence-based techniques just as much as they use a “sense”, a “gut feeling” for the patient. I’m not talking about hocus-pocus like reading auras or energy healing. I’m talking about old-fashioned personal connection. About people listening to, and empathizing with, people. People who are sick. People who are in pain. People who are asking for help. Often times what they need from caregivers is not something that can be encoded or quantified. And frequently the key to diagnosing the illness had more to do with careful listing and observing than running more tests and churning a patient through an algorithm. Be careful not to engineer the human connection out of the picture.
10. Hospitals don’t want to just be a safety net
Though they often end up as exactly that, hospitals don’t want to be a place of crisis. No one is wishing for more people to get sick. No one likes seeing patients return and return again with serious complications. Hospitals wish they were centers for the occasional tune up. Kaiser, the massive healthcare/insurance company on the west coast describes itself as a “health maintenance organization”. This is not just some altruistic stance, it makes better business sense. If the bulk of admissions were people who came in for elective or scheduled procedures, there wouldn’t be such an issue with beds, payment, stress and disruption of patient’s lives and so on. As it stand, the majority of all admissions for most hospitals come in through the emergency room. We’ll never get rid of the need for emergency care, but if The Cathedral could become more of a center for healthy living in the community, I think we’d all be better off.
Photo by Steven2358 used under Creative Commons License