Digital Medicine and the *Systems-based* Innovation Mindset

If you are reading this blog, we likely have some things in common: frustration with excess costs in healthcare, impatience with the pace of change in the industry, and discouragement about inequality and the inability of the current system to meet the needs of patients. At the same time, we likely also share the same optimism that technology holds enormous promise to fix these many important issues.  

As many of us already know, technology alone doesn’t solve problems; technology is a tool. At a minimum, new technology can enhance the efficiency or quality of an existing care process; at its very best, digital technology can enable new, high functioning systems of care that transform patient and clinician experience, banish waste, and create measurably superior outcomes. 

So how do we achieve the first and strive for the latter? Find a great partner to pressure test and pilot a solution. A courageous partner with tremendous unmet needs and a disciplined process for designing, piloting, and scaling innovation.  

On my second day at DiMe, I had the pleasure of attending a virtual fireside chat between Dr. Ryan J. Vega and IMPACT co-founder Don Jones during an IMPACT Virtual First Care collaborative steering committee quarterly meeting. The topic of discussion was, “What can we learn from the VA on their approach to testing and deploying innovation?”  

As Chief Officer of the Office of Healthcare Innovation and Learning at the Veterans Health Administration (VHA), Dr. Vega is responsible for discovery, testing, and scaling new ways of taking care of 20 million United States veterans. In some ways, the VA provides an ideal sandbox for innovation: 

• Longitudinal Care Mission: A unique mission to provide care, not just healthcare, longitudinally over a lifetime, so whole person issues like housing security are also in scope
• Aligned Incentives: A payer-provider structure that incentivises a balanced focus on value – experience, cost, and quality 
• Long View: The absence of member turnover, which justifies large up-front investments in investments with long time horizons of return, such as precision medicine
• National Delivery Infrastructure: Healthcare delivery infrastructure with a national footprint and unified medical record serves as a proving ground for piloting innovation

As ideal as this sounds, without a strong discipline of innovation, these features could also be a recipe for spectacular and expensive failure. But VA is enjoying enormous success in digital innovation, a leader in the field despite being the largest integrated healthcare system in the country. Based on what I learned, here are the three keys to success that all of us advancing digital health innovation to improve lives could learn from:   

1. Systems-Based Innovation:

“It’s a platform approach, not a pipeline model.”

As described by Dr. Vega, innovation within the VA is carefully targeted, field tested, and appropriately scaled and integrated into systems. For example, consider the VA approach to bringing remote diabetic foot monitoring in the PAVE program. The Prevention of Amputation in Veterans Everywhere Program is an ongoing VHA directive to reduce the impact of diabetic foot ulcers, a problem leading to ~$3.5 B US annually in costs due to amputations, with sobering mortality rates approaching 20%. A few principles for adopting new technologies within such an initiative, including digital devices, stood out for me: 

• Prescriptive and targeted: Mine data to identify patients across the system in the highest risk strata and selectively target those populations to receive the intervention, e.g., digital devices
• Automation: Establish wrap-around systems to automatically ensure correct and timely action; alerting providers, auto-scheduling visits, and referrals
• Scale optimization: Prove out the innovation at select motivated sites, then rapidly scale only what works. The diabetic foot mat program is now deployed to ~90 centers.
• Commitment to evidence: Rigorously collect real world outcomes, including cost, health services utilization, patient experience, and meaningful outcomes measures. In this program, the results were a 50% reduction in limb amputation, a reduction in skin grafts, ED visits, with 87% patients adhering to the protocol

To see the VA innovation engine in action, check out the Prevention of Amputation in Veterans Everywhere (PAVE) Program. 

2. Integrated Systems of Care:

“It is not a first mile, last mile problem, but the entirety of the race.” 

As a payer, the VA contracts with non-VHA providers as needed to complete networks as part of the Community Care Program. Familiar concerns such as managing patient experience and quality within the network, effective transitions and coordination of care, and in-network retention are omnipresent. 

So how do new models of care such as virtual first care figure in network development? The answer is, seek opportunities along the continuum – the entirety of the race – to reduce preventable costs and improve outcomes, create access where none is available, and delight patients and providers by including them in the design process. For the VHA, current priorities include improving access to PT/OT in the community, investing in services to prevent urgent care and ED visits, and redesigning the care and wrap-around systems that enable aging in the home.  

3. Accountability to Meaningful Outcomes:

“It is incumbent upon U.S. healthcare systems that we make better determinations about what care is actually working. We’ve got some good process measures, but how do we know if it’s a good outcome?”

We pay more per capita on healthcare than any other nation. In return we “boast” the highest burden of chronic disease, rampant health inequity, and – even before the pandemic – declining life expectancy. Healthcare as we’ve provided it to date is not working. 

New approaches offer hope. Measured by outcomes that matter to patients and physicians, virtual first care (V1C) for diabetes works. Telehealth for mental health? It works. The list goes on. 

But we can’t innovate on an island. V1C is not virtual only care. It must be fully integrated as a prescriptive and targeted solution, automated where possible to account for the healthcare staffing crisis, appropriately scaled, and held to the same standards of performance as traditional care.   

High-value care is defined by improved access, equity, efficiency, and effectiveness. VA is already getting it right. Our IMPACT community is, too. 

Throughout my first 10 days at DiMe, I have connected with numerous members of DiMe and the IMPACT ecosystem. I am humbled by the passion and ingenuity of this community. One member’s comment regarding market strategy really stuck with me: “We’ve pivoted. It’s no longer just about the technology, it’s how we integrate our solution into workflows to craft better systems of care.” Nailed it!

Interested in learning more about effective V1C? All IMPACT resources and toolkits are available to the public. Want a seat at the table shaping the future of digital medicine and V1C? Please reach out to discuss joining us!