Profile in Leadership | Innovation Is Not Primarily About Technology

With a curriculum vitae placing her at the summit of healthcare technology leadership in the U.S., Molly Joel Coye, MD, chief innovation officer for UCLA Health System, is well placed to survey the landscape and distinguish the evolving from the endangered—and that means not just technologies but also care-delivery processes.

Former commissioner and director of two state health departments (New Jersey and California) and erstwhile chair of California's first statewide health information exchange (HIE), today she heads up UCLA's Institute for Innovation in Health and serves on the boards of various healthcare nonprofits, associations and companies. Her professional past also includes the headship of the hygiene and public health practice at Johns Hopkins University in Baltimore, a stint in product development for an internet-based disease-management company and a time advising investors in health technology ventures. CI+T asked Coye what has lately caught her eye as hot and what has not.

September brings your second anniversary as chief innovation officer of a large, teaching health system. What sorts of innovations have stood out for you so far?

Since this interview comes on the heels of the Supreme Court decision [to uphold the Affordable Care Act], it would be hard not to note that any innovation within an individual health system is swamped by the innovation of trying to make sure all our patients are insured and have access to care—and also, not unimportantly, that we will actually be paid for the care.

Secondly, the U.S. hit a new kind of tipping point for innovation when the Centers for Medicare and Medicaid Innovation put out their call last fall in the Innovation Challenge Fund. The particularly exciting part of that was that respondents were asked to account for how they were going to reduce the net cost of care, and to spell that out specific to each innovation in service delivery. Many health systems had been asked in the past to reduce unit price but not to redesign care in order to make it more efficient, end to end. It's important to point out the tremendously exciting, liberating and incentivizing fact that health reform will have on delivery systems.

Along with the positive incentives will come some new pressure points. How does that figure into your thinking?

You often find the best innovations come when there's a burning platform. The military has been a source of very important innovations precisely because they have to operate under conditions of war and, in between, prepare for wartime conditions. That forces a very high degree of innovation at, for example, DARPA (the Defense Advanced Research Projects Agency) and TATRC (the U.S. Army's Telemedicine & Advanced Technology Research Center).

At UCLA, the most exciting innovation is developing the next generation of primary care innovations—building on the patient-centered medical home, but facing the problems that everyone in the country will confront: too few primary care physicians and a huge demand for really convenient and satisfying and motivating care rather than simply churning people through the office.

UCLA has a large primary care operation of academic medical centers. We see more than 200,000 patients a year for primary care, and we have 25 years of experience with contracts for managed care. We have a toehold on the future and on the kinds of changes that will be needed in order to support care for very large populations.

Some of the elements that we've been introducing shift care into the home. Some of them ally with community service providers such as social workers and community health workers who have emerged to meet community needs without being hospital-based. And some of our innovations utilize social networking and internet-enabled solutions that meet our patients' needs without making them come to our clinics or see our primary care physicians (PCPs) as frequently as they have in the past.

Some have observed that innovations in the delivery of care expand as technologies evolve to facilitate them. Would you comment on that?

Innovation is not primarily about technology, but it is almost always enabled by technology. For example, we are building an e-referral and e-consult system so that referring specialists and PCPs, either in our network or not, can use a very simple, convenient browser platform to directly exchange information and get curbside consults from our specialists.

We expect this will mean that more of our referring physicians will keep patients they would have referred to us in the past—which sounds contradictory, but the goal for all of us should be to practice at the top of our license. If PCPs and community-based specialists can handle more of their complex patient cases, it's better for them and it's more convenient for the patients.

From our point of view, we don't want to just get a share increase in volume; we want an increase in the number of cases that appropriately require tertiary and quaternary services. We want to help community physicians increase the number of patients they can deal with appropriately.

Let me give an example from the primary-care innovation model: home-based medication reconciliation. The usual approach is to have patients bring a brown paper bag with all their medications into the office, and our community services partner has found that it's less expensive and very feasible to have a trained lay worker with a tablet go out to the home and actually look in the medicine cabinets and scan the medications. That information is wirelessly communicated back to a pharmacist who can review the medications and identify which patients need to come in for an appointment.

In each example, the technology is relatively straightforward, but it enables new service models that reduce costs and improve care quite impressively, especially in terms of efficiency.

What partnerships have you formed within the community around those goals?

That's been a very exciting area. This fall, we expect to launch our in-home palliative care program, where we will call on social workers as well as clinical personnel to visit with patients, their caregivers and family members—in the home to discuss the course of care when they have highly complex, potentially terminal conditions. The idea is to make sure those conversations happen before the patient gets hospitalized again. This is a model that was originally developed by Partners in Care Foundation, the evidence-based developer of community services. They use IT very heavily, which is unusual for providers of community services. It's very exciting to work with them because they help us meet the needs of the patients in the community.

The in-home palliative care program works with patients in what is expected to be their last years of life. At another institution, the program reduced the net cost of care in the last year of life by 30 percent. We're going to be supporting it with more IT connectivity in the home than was possible with earlier models. We're very excited about this, because the satisfaction levels for the families and the caregivers, as well as the patients, are very high.

What role does a chief innovation officer take in these kinds of programs and enterprises?

I head up the initiatives but always in partnership with an operational lead. Our job at the UCLA Institute for Innovation in Health is to scan for novel approaches and work with our operations folks to study those approaches and decide which ones we want to bring in-house. Sometimes they are innovations developed by our own faculty, but very often they come from outside. After we decide to proceed with a project, we support the process of learning and deployment. We, at the institute, are not an operating unit; we're like a think tank inside the organization, but we're somewhat protected because you have to expect that you're going to get failures when you're trying new things.

We're given a great deal of support by the executive team and by the physician leadership. We enjoy a very privileged position within the health system, and we feel a great deal of responsibility with it.

What level of leadership within the organization are the operational leads from?

In the primary care innovation work, our operations lead is the chief medical officer of UCLA's practice medical group. In the case of the e-referral initiative, our champion is the chair of neurosurgery. It's important that the operational leads are top-level clinical leaders in their respective areas. That communicates that the work is very, very important.

What technology or combination of technologies are you most excited about right now? Also, have you seen any that seemed promising but recently proved disappointing?

Tele-ICU is very near the tipping point. Currently, 13 percent of ICU beds in the U.S. are managed through a telesolution. Many places began with two-way audio/video and have moved on to streaming data from all the bedside monitors in the ICU. Some people have said, 'One technology will replace the other.' This is a good example of a very effective combination. There are some clinical settings where, for example, you're operating a tele-ICU but you want to get some consult on the floor or in a skilled nursing facility where you're not going to have monitored beds. In those cases, having a mobile unit from your tele-ICU vendor or a separately obtained two-way telemedicine unit that you can take as a computer on wheels onto the floor into a different setting, like a SNF, can provide a tremendous help.

We're seeing here an example of a technology that didn't so much disappoint anyone, but evolved to meet a far more complex set of needs. You have to become fairly sophisticated in your management of all the different modalities.

The role of the CIO and CMIO and those who are knowledgeable about emerging technologies is changing from introduction to understanding that we're into the second and third generation of many technologies, and learning how to balance and combine them appropriately.

What technology impresses you the most right now?

There are a couple of things that are the 20 percent solution. Everybody talks about how there is 30 to 50 percent of excess expenditure or quality problems in healthcare, and I'm pretty impressed if a solution can deliver a 20 percent improvement. There are a couple of things that fall into that category, and tele-ICU is one of those. It offers—pretty routinely, across the board—a 20 percent decrease in mortality and a 20 percent decrease in length of stay and cost. That's across 13 percent of ICU beds in the country. If the FDA were evaluating it as a new pharmaceutical, they would call it a blockbuster drug. It has such a reliable, important positive effect and yet it has taken 10 years both for the technology itself to improve and for healthcare providers to accept a very new way of providing care. It's been very exciting to watch this get to the tipping point, and it will bring a major improvement in quality and cost of care in the future as it spreads.

What attributes do you feel vendors should be emphasizing as they develop and market new products, services and systems?

First, they should all look at their new product development, along with marketing and sales, through the lens of reducing the net cost of care for patients—whether it's the annual local budget for their care or an episode bundle of care. If [vendors] are not contributing to a net reduction in the cost of care, it's going to a lot tougher to sell into this marketplace.

Second, usability is becoming ever more important, given the complexity of each technology and the demands for integrating information from each device into a common medical record. Today, ease-of-use is not just about simplicity in manipulating the device; it means that information from the device is easily integrated into a large number of EMRs. That can be a huge barrier, because if you're a physician in charge of coordinating care for a set of patients, and you've got data streams from 10 or 15 different devices, your workload is going to be near impossible to manage. It's already been challenging and it's only going to get worse.

Third, with the tremendous emphasis on primary care, vendors need to target more and better tools to PCPs—tools that can save them time and facilitate not only getting tasks done but also building relationships of trust and a solid bond with their patients. That's already very important, and it's not going to become less so.