Rethink health care by thinking like a startup: Using creativity and managing uncertainty to design the next generation of health services

Onil Bhattacharyya Frigon Blau Chair in Family Medicine

Women’s College Hospital, University of Toronto

Our Next Role Model?

Canadian Health Expenditure 1975- 2014

Canadian Institute for Health Information, 2014

Health Care Spending Dominates other Determinants

Health 40%

Education 20%

Social Services

12%

Post secondary education

5%

Other 23%

Ontario Government Spending, 2011-2012

Shrinking Tax Base

The Global and Mail, 2012. Based on data from Statistics Canada.

27%

28%

41%

4%

Top 1%

Top 2-5%

Top 6-49%

Bottom 50%

Top 5% of users account for 55% of expenditure

Rosella et. al, BMC Health Services Research, 2014

Costs are Driven by Subset of Patients

Typical Complex Patient

Osteoarthritis

Diabetes Heart

Disease

Multiple doctors

Multiple medications

Inactive

Limited adherence

Depression/anxiety

Poor coping skills

Low income

Poor social support

Shift in Health Care

Old School

• Infectious disease

• Hospital-based care

• Success in surgery and care protocols

New School

• Chronic disease

• Ambulatory care and self management

• Interactive model to increase effectiveness and appropriateness

Fundamental Paradox

• The highest users have the worst outcomes

– Partly because they are very sick

– Partly because we are not addressing their true needs

“I knew I couldn’t do the things they were asking me to do. So, I just sort of gave up. I knew I would end up back in the hospital.”

Kangovi et. al, Journal of General Internal Medicine, 2013

Because care is designed….

To be easy to implement, not use

By people who rarely use it

None of whom have complex needs

Why do high users experience unmet needs?

Old school approach: the target groups, interventions and outcomes were relatively straightforward, so we focused on delivery.

New school approach: we don’t know what to deliver, we need to generate and rapidly test a range of approaches.

The old days Services organized by organ

More recently Services organized by disease

Next wave Services organized for people

Victor Montori, 2010

How do we do this?

1. Understand what to aim for

2. Find a method to get you there

3.Deliver it consistently

Solution Continuum

Design Thinking

Lean Start Up Quality

Improvement

1. Aim 2. Build 3. Deliver

“If things are fundamentally working in your system, then you are operating in the world of improvement. ”

“If you fundamentally believe that what you have is broken, then you are operating in the world of innovation.”

Kaiser Permanente Innovation Consultancy

Reaching High Users

Improving care – reducing wait times, improving outcome measures, reducing errors.

Innovating care – fundamentally changing how care is conceived and delivered.

Aim - Design thinking - Use empathy with users to inspire new

approaches

- Use personas to make care person centred

Personas of High Users

Medical Support

Social Support

Sporadic Issues

Persistent Issues

1. Medical Complexity/Frailty

2. Severe Relapsing Condition

4. Convergence of medical / social /

behavioural issues

3. Diagnostic Uncertainty

Medically Complex/Frail

Expertise – Tech Expertise – Health

Mr. S •93 years old •Lives in condo in central Toronto w/ wife •Retired dentist

Health Profile: •Severe hip OA •Congestive heart failure •Prostate hypertrophy •Intermittently confused

Must do: •Wife makes major decisions •Minimize size of care team

Never do: •Bring to hospital for anything other than MI or coma

Service Platforms •Poor mobility •Dr. home visits •Home blood work •Some CCAC medical assistance

Fears • Loss of autonomy Hopes •Continue to live in condo independently with wife

Experience goals •Improve mobility •Avoid hospital •Stay with wife •Maintain dignity

Patient on

Screen

Family

Doctor Resident

Physio

OT

Pharmacist

Social

Worker Community

Nurse

Dietician

Psychiatrist

Internist

IMPACT Plus

From Lean to Lean Startup

Build - Managing Uncertainty

Learning from Startups

• A startup is searching for a viable and replicable business model

• Generate and test hypotheses

• Early and frequent customer feedback

• Radical empiricism reduces risk

Finding the right patients, Building the right program

Adapted From: Blank, S. Harvard Business Review, May 2013

User Discovery

User Validation

Recruitment Program Building

Search Execute

Change user or Intervention

User Discovery

• Build and test a minimum viable product

• Decide if you need to pivot because it’s not working or persevere because it will

Minimum viable product (MVP)

• MVP provides a solution to problem with the least amount of functionality

– Design an MVP to help gather information

– Design small

– Design to learn

If you are not embarrassed by the first version of your product, you’ve launched too late.

- Reid Hoffman, LinkedIn founder

SCOPE Services GIM

Internal Medicine On-Call

Community Care Access Centre (CCAC) Care Coordinator

Nurse Navigator

Primary Care Provider

SCOPE Network GIM

Internal Medicine On-Call

Community Care Access Centre (CCAC) Care Coordinator

Nurse Navigator

Acute Ambulatory Care Unit (AACU)

Telephone Advice

Community and Home Supports

CHF and COPD management via telehomecare

Intensive case management/patient follow up

Imaging consultation

Diabetes Education Program (Portuguese)

Specialty Referrals

Mental health/depression urgent psychiatry

CACE Complex Care Clinic

Addictions Medicine

Virtual Ward

Telemedicine Impact Plus

Health Coach

Building the Right Program

• Problem: Some solo GPs have many patients who go to the ED

• Assumption: Providing phone consult service to these GPs will avoid ED visits

• Reality check: Pilot data shows that 50% of patients go straight to ED

• Hypothesis: Targeting patients as well may increase impact

Test Minimum Viable Product

– Assumption: we can’t select patients with unmet needs, but they might self-select

– Initial data: Issues arise at 2 weeks

– MVP: letter mailed to every patient after ED visit with MD’s number

MVP

Test MVP

– Test: 100 letters mailed to patients

– Result: 4 phone calls in 2 weeks

• 1 request about MRI booking date

• 1 wrong number

• 1 question about help with transportation to doctor’s appointments

• 1 call back – person not aware of having made call

“Failure sucks, but instructs.”

Bob Sutton and Diego Rodriguez, cited in “Creative Confidence”

“A pivot is a change in strategy in pursuit of the same vision”

-Eric Reis

Pivots

• Zoom in/out

• User segment pivot

• User need pivot

• Business architecture pivot

• Channel pivot

Adapted from Eric Ries, “Lean Startup”

Pivots

• Zoom in/out

• User segment pivot

• User need pivot

• Business architecture pivot

• Channel pivot

Adapted from Eric Ries, “Lean Startup”

Time

Disease intensity

Care intensity

Providing Right Care at Right Time

Hospital

Rehab

Home

Hospital

Rehab

Home Home

Hospital

Long-term care

Not enough care

Too much care

Home Care Family

Physician

Hospital

Virtual Ward

Virtual Ward Program

Findings: In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge.

Home Care Family

Physician

Hospital

Virtual Ward

Taking the Next Steps

Creating Seamless Care

Primary Care Provider

Assess In-

Person

IMPACT Plus

Non-Urgent

Urgent Virtual Ward

How do we get more of this?

Incubator

• Source, support, and grow new models

Accelerator

Early ideas Long engagement

Limited engagement Developed models

BRIDGES is an incubator testing 9 models

that integrate primary, hospital and

community care for patients with medical,

mental health and social needs.

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Our Next Step: The BEACCON Incubator

• Integration is hard work

• Many models will need to be redesigned and recombined before they succeed

• System changes should be tested with practice changes

• Similar approaches can be used to integrate across sectors

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Implications for Ontario

Features Lean

Typical problem

Improve uptake of hand washing

Goal

How to deliver service better

Parameters

Clear user and outcome

Strategy

Iterative, tests of smaller breadth

Lean Startup

Improve access for frail elderly

Develop the appropriate service

Tentative solution, user and outcome

Iterative, tests of larger breadth

Thinking like a Startup

Reflections

• Assume it isn’t going to work initially

• Pace yourself

• Document your journey

• Keep reaching

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