Health care is unlike other industries in a number of ways. Notable among them are the constraints imposed by regulation, the dependence on a third-party fee-for-service payment system, and the reliance upon human expertise (clinicians) to deliver services. As a result, many interesting ideas — both from inside health care and from other industries — are stymied by the realities of attempting change in such a complex system. Innovation done for its own sake, or innovation attempted without regard to the context of health care, is doomed to failure.
At NewYork-Presbyterian, we have learned from our own experience and that of our peers that pilot projects in health care, particularly those involving technology innovation, require 90% of the work of a full implementation but often result in a dead end. For that reason, we prefer to focus on large-scale challenges that can be addressed with technology that can be quickly scaled across the enterprise.
It was in this context that innovation groups at NYP began looking at the opportunities and challenges posed by telehealth. We saw a need to develop and apply a structured approach — what we came to call our innovation stack — to our innovation processes as a way to achieve sustainable change across our entire organization. Adopting this construct enabled us, in under a year, to build NYP OnDemand from a concept into one of the most comprehensive telehealth programs in the country.
In the world of computer science, the term “stack” refers to the full range of hardware and software necessary to create a complete platform capable of running applications. At NYP, we have borrowed that term to describe the range of activities that we believe are necessary to ideate, design, implement, and manage innovation at a major academic health center. Our innovation stack consists of a set of six interrelated activities intended to achieve the leadership, front-line buy-in, and engagement necessary for successful innovation.
Beginning in early 2015, our Innovation Center and NYP Ventures groups oversaw the creation of NYP OnDemand along the six dimensions of our innovation stack.
- Scope the challenge. Our first step was to identify at a high level the problem we wanted to solve. NYP continually seeks to optimize the deployment of clinical resources while also improving patient access, and we thought telehealth might offer a significant opportunity to achieve these goals. (We had some experience in telehealth, having launched a successful telestroke program to earn stroke certification at one of our community hospitals in 2013.) Consequently, we met with stakeholders across NYP, as well as at Weill Cornell Medical College and Columbia University College of Physicians and Surgeons (NYP’s affiliated medical schools), to identify opportunities and challenges associated with implementing a telehealth program. They helped us develop and refine use cases, such as peer-to-peer emergency department specialist consults for stroke, psychiatry, and pediatrics. Through this process, some of these stakeholders became our early internal champions.
- Research solutions. Our research efforts occurred in tandem with the first step, as we supplemented our internal conversations with external analysis of opportunities, challenges, best practices, and possible solutions. This included researching the current state of state and federal legislation and regulation on telehealth, and speaking with several leaders in using telehealth, ranging from other academic health centers to the Veterans Health Administration. The result was an internal whitepaper that was shared across the organization and was used to set expectations among the members of our Steering Committee.
- Identify best-of-breed vendors. Our Innovation Center led a rapid-cycle evaluation process in which we reviewed 35 telehealth vendors that had been identified in our research process, in order to produce a small number of finalists. This process also enabled us to understand what internal capabilities we would need to develop ourselves, such as creating new clinical workflows and integrating telehealth into our patient-facing app. Ultimately, we chose three vendors based on their relative strengths: American Well, Grand Rounds, and Avizia.
- Implement solutions. Our Steering Committee chose three initial use cases — the peer-to-peer ED specialist consults, remote second opinions, and remote follow-up visits — by balancing the greatest need against speed to execution. Working with the selected vendors, the Innovation Center led the technical implementation, while the Steering Committee created workgroups to identify clinical champions, develop workflows, address legal, regulatory, and billing issues, and create performance metrics. We phased in each use case, starting with a single campus and then rolling out across the enterprise (six campuses in all) after resolving challenges.
- Scale through partnerships. After gaining experience implementing and managing NYP OnDemand across the enterprise, we began establishing partnerships with organizations with broad consumer reach that can help us achieve additional scale. We are speaking with local and national consumer-facing companies, such as cell phone manufacturers and pharmacies, about leveraging their distribution platforms to broaden the reach of our NYP OnDemand programs, and offering to deploy NYP OnDemand to help large employers manage their employees’ health needs.
- Make venture investments. Our internal and external research and vendor evaluation efforts enabled us to develop a robust market map for the telehealth space. As we selected the vendors to roll out NYP OnDemand, we saw an opportunity to invest in one of them — Avizia. Given the stage of the company (an established hardware company rolling out an integrated software platform) and our 3-year experience working with their technology (we had used their hardware to launch our telestroke program), we saw a compelling opportunity to add value to both our organizations. Our goal is to foster a virtuous circle, where we are able to help Avizia refine their product offerings and thereby improve NYP OnDemand, while also capturing some of the upside through the increased value of our investment.
Since the launch of NYP OnDemand in July 2016, it has already become one of NewYork-Presbyterian’s core service offerings — so much so that we are committed to having 20% of our patient encounters occur virtually by the end of 2018.
This blog post originally appeared in NEJM Catalyst on May 16, 2017.