Implement Like a Startup & Go Mobile in the Healthcare Enterprise
Today’s clinicians are living a double life; the modern one where their world of indispensable services and social networks are at their fingertips on their mobile device, and their job in the healthcare enterprise, twenty years in the past. The overwhelming majority of healthcare workers have smartphones and have become comfortable with connecting with family and friends around the world with FaceTime and ordering a car service at a tap of their Uber app. While at the same time, they step into work in a modern healthcare organization and peck away at keyboards and stare at desktop computers with painfully designed user experiences much of their day.
The digital divide is widening and increasingly, healthcare providers are expecting a more “consumer-like” experience in accessing and providing care. One that delivers the same elegant user experience, thoughtful design and seamless mobile access as the other apps on their smartphone. Startups have capitalized on this opportunity by taking apps and services that have been built for the consumer space and applying it to the uniquely antiquated healthcare environment. And established companies are quick to innovate within to prevent being disrupted by the consumer demand for mobile solutions. Increasingly, clinical mobile apps provide a convergent solution bringing efficiency, productivity and risk mitigation to the modern healthcare organization.
From purchasing a HIPAA secure texting app from a then startup to rolling out a dedicated electronic health record (EHR) for the iPhone and iPad from an established vendor, we’ve now successfully implemented two clinical mobile solutions in a “bring your own device” (BYOD) environment. These each provided their own education about both the challenges and benefits of going mobile in a large academic institution. Here we share our experience at Boston Children’s Hospital (BCH), lessons learned and best practices in implementing BYOD clinical mobile solutions and how to succeed by being different and acting like a startup.
Identify a Problem
The above scenario was a situation I was quite familiar with in 2012 when I first appreciated the growing problem of communication in healthcare. A more recent 2015 study showed that 84% of physicians had smartphones and in a related 2014 study, nearly the same percentage were texting patient-related data.[i],[ii]. Added to that was the pain of pagers and the one-way, excruciating workflow of using them as a form of communication. Like the genesis of any solution I thought to myself, “there has to be a better way”. Naturally, I wasn’t alone, and a quick perusal of the Apple App Store revealed a handful of startups and established vendors already addressing this exact pain point.
Evaluate the Market
As with any software solution, one must establish a keen understanding of the landscape and where to invest their dollar to provide maximal value for their organization. Not unlike any other industry, healthcare has many nuances and unique barriers that have challenged the recent innovation seen in other industries such as travel and financial services. Similarly, established vendors are the preferred path for adopting new solutions for a number of reasons including trust in security practices and existing pricing and legal contracts that may already be in place. Security is a particularly challenging point as large academic environments in particular demand very tight control over their data and concepts like remote hosting and “the cloud” are generally very unappealing (although sentiment is changing very rapidly).
However, in the world of mobile, disruption is king and healthcare entrepreneurs are seizing opportunities to nimbly and cheaply build solutions that are increasingly compelling. Appealing to the new breed of digital natives in healthcare and those longing for the consumer experience in their day jobs, startups are leveraging slick user experiences, clean design and the power of the cloud to offer impressive solutions. While HIPAA compliance was once an offering one had to question, the expectation now is that healthcare software startups are willing to sign business associates agreements (BAA) and use trusted HIPAA compliant cloud solutions such as Amazon Web Services and Box as examples.
Another question that well-resourced healthcare organizations with internal IT programs debate is to buy or build. Increasingly, with speed of development and ability to raise venture funding, healthcare startups are far outpacing the ability of internal IT shops to compete with their offerings. Of course, the challenge of integration remains, however it is improving over time, particularly with the promise of interoperability from the Office of National Coordinator and platforms such as SMART (a project run out of Boston Children’s Hospital Computational Health Informatics Program) and FHIR.
Given the majority of mobile solutions are dependent upon an “app store” for distribution, the best place to start a market assessment is in fact the Apple (App Store) and Google (Play) app stores. In the case of our initial evaluation of secure texting, at the time of first setting out in 2012, there were perhaps five apps available. Just like picking the best non-medical app on the store, a quick perusal of the app details, screenshots and reviews can often separate the wheat from the chaff. Beyond the initial cursory review, a deep dive is necessary with each chosen vendor, discussions of features, timelines, integrations and costs which will be a time and resource consuming process.
Pilot
How does one decide which solution to go with? In truth, the decision is challenging with many stakeholders and decision makers as well as issues of cost, trust and weighing established vendors versus working with a startup. The great equalizer is data, however, and the voice of the end user. Taking a page out of the startup methodology, do A/B testing and get stuff in the hands of users, get their honest feedback, survey and study their use of the solution and analyze the data. This, in concert with the more traditional evaluation tools of assessing cost, projecting return on investment and comfort with companies can be invaluable.
Piloting is both an art and science and its process and value should not be underestimated. One must be careful however to pick the right cohorts to study. To offer a real-world flop as an example, studying the value of a secure text messaging solution with a team of doctors that work in the same room together all day, did not help generate the use and data one might hope to use to evaluate a solution. It is worth spending time strategizing a priori where one expects the most value will be demonstrated with a given solution and battle test each of the apps one is considering.
Further, one must set realistic expectations for the experience the “pilots” can expect. Managers of a pilot should strive to create a process that values user’s feedback and allows them to feel they are part of an exclusive experience. Like the hottest startup or Kickstarter project that generates a faithful longing for their product, and a willingness to be an early adopter, “beta testers” should be accepting of the fits and starts these projects often experience but feel like they are part of an exciting process. This mindset is particularly novel in a traditional healthcare software implementation and can help build a fan base, promote local champions and ultimately spur organic growth.
Testing out an app in your real world environment is not simply an opportunity to test a product but should be looked at as a chance to push on the company and the product to drive it toward your needs and aspirations while at the same time evaluating the working relationship with the company. In our experience, it was during the pilot phase when companies are most receptive to feedback and willing to “tweak” their product to lock in a sale. Similarly, it is during this time that relationships are developed and trust is built, whether it is with an established vendor or early startup.
Lastly, piloting is not just about evaluating the solution and the vendor but a chance for you as the sponsor to find the holes in your organization, identify the challenges and establish your practice around a future marketing plan and implementation at scale.
Pave the Runway
There is nothing worse than spending lots of time, effort and money on a bright, shiny object only to see it fail to launch or bomb because of an unanticipated challenge from infrastructure, policies, culture or expectations. It is therefore imperative to identify these challenges early by building a multidisciplinary team of stakeholders and institutional leaders, commonly referred to as an “advisory board” in startup parlance. Such a group will ensure you not only have “buy-in” from leadership but will also inform you of the nuanced challenges in different groups and the unique obstacles culturally and politically. This will allow you to craft your education, marketing and setting of expectations appropriately to each constituent.
In the world of mobile, connectivity is everything. One must ensure that especially with a clinical mobile solution where critical communications and clinical data are expected to be ironclad, systems are battle tested. Even the best mobile app will fail if the user can’t get a reliable Wi-Fi signal or spends their time in a cellular dead zone. Part of the value of mobile solutions in a clinical environment is the redundancy of the Wi-Fi and cellular networks. Before any mobile solution is generally released in a healthcare environment, one must work closely with the networking and IT teams to identify areas with inadequate Wi-Fi or cellular coverage. Similarly, security of these devices is critical and each organization should review their policies and procedures on mobile device management, particularly in a BYOD environment.
Even in 2016, many organizations continue to maintain wireless policies that conform to the guidelines established in the ECRI 2006 report[iii], a full year before the birth of the iPhone. Such recommendations suggested keeping all cellular devices at least three feet from any medical device for fear of interference, a recommendation that in practice would effectively not allow any modern clinician in any clinical space in a hospital. Fortunately, in 2013, Boston Children’s Hospital Biomedical Engineering team tested every type of medical device we had at the time in a worst-case environmental scenario. With maximal cellular output of multiple modern smartphones, we were unable to document any interference whatsoever.[iv] Such a finding allowed us to comfortably recommend a revision of our cellular policy and brought the policy in alignment with a burgeoning ecosystem of clinical mobile solutions.
Build a Launch Team
Once a product has been decided upon, there are a series of steps necessary to develop a “go-live” plan. Of critical importance is to build the right launch team; often a combination of both internal clinical and political stakeholders and technical personnel working alongside the solution partner. Together, a marketing and training strategy can be developed and materials generated to complement these efforts. Critical to success, particularly in a busy academic environment are local, clinical champions. Often, these are the same doctors, nurses and providers that helped beta test during your pilot and will help educate and engage their colleagues in the workflow that makes sense to their unique jobs. Having the multidisciplinary “advisory board” will prevent missteps and help the launch team focus its attention in the areas where adoption will be easiest and provide the most value. So-called “quick wins” with specific groups or workflows are a great way to get the project off the ground and build a user base right at launch.
Education & Onboarding
Flexibility is something that both large corporations and traditional software implementations in healthcare are not familiar with. Often unique to well-designed mobile apps is a certain intuitive nature, particularly to digital natives. However, it would be a ruinous error to assume that all users are tech savvy or of the same mindset about clinical mobile solutions. Furthermore, cultural differences (i.e. doctors versus nurses) cannot be underestimated as the opinions are nuanced and unique to each provider’s role, age and comfort with technology, unit, floor and institution. As a gross generalization, many nurses are thoughtfully concerned about how patients might perceive their use of a personal mobile device and distraction in a clinical environment. Whereas, most physicians are casually unaware and happy to carry a device that might make their lives a little easier. While efforts in marketing, policy revisions and top-down endorsements are helpful, cultural differences can and will lead to challenges unless anticipated and mitigated where possible. Mandating use, where feasible will lead to the best outcomes as was the case with our pediatric residency program and their ubiquitous use of secure messaging as their chosen mode of communication.
In contrast to a typical EHR product roll-out where all users are generally on-boarded, a mobile app may often be optional. This can make training and rolling out easier but may also lead to fractionation, lack of adoption and a missed opportunity to take advantage of the value of the network effect and virality that can truly be powerful, particularly with a mobile app. As the sponsor of a project, you may deeply believe in the value of a product, its intuitive nature and mistakenly expect that all others in your organization will follow suit. What may seem like a no-brainer to adopt for some users is a serious barrier to others. Therefore, developing compelling use-cases and integrations with workflow to clearly demonstrate utility will be critical. Furthermore, developing a fan-base and exemplars will provide the peer-pressure often necessary to get the network effect that truly delivers value for the organization.
Follow the Data
As startups scale and build a user base, they are sharply obsessed with data and analytics. This allows them to extract a great deal of understanding of how and where their product is being used, drive adoption, and re-focus efforts. In a soft-launch such as our roll out of TigerText, following the usage data unveiled a completely unexpected top user and a workflow that when supported led to tremendous return on investment. Having access to your organization’s data with an administrative “dashboard” will allow you to have deep insight into the trends of use, what individuals, groups and functions are being utilized and again further drive adoption, identify valuable use-cases and challenges.
Continue to Iterate and Grow Organically
Like any successful entrepreneurial venture, the product is never complete and there is a constant drive towards developing insight which will lead to innovation, and improvement. Whether a home-grown app, an early-stage company or a Fortune 500 vendor, the product will continue to develop and mature over time. Play an active role in sourcing ideas for your users and value-driving use-cases in your organization. Feed these ideas, workflows and integrations back to your vendor to further drive the solution to better fit your unique needs. A partner who is receptive to feedback and suggestions for improving their product represents an invaluable opportunity and should not be underestimated. In particular, a startup or nascent venture who is laser focused on improving their product and demonstrating value in the marketplace can be a fantastic ally and work hard to ensure your success as it can often translate to their own.
Summary
Now, more than ever, there is a tremendous groundswell of interest, money and resources begin poured into helping the healthcare industry cater to their mobile workforce, like other industries have already adopted. Leveraging these technologies and implementing them strategically to frustrated clinicians will deliver great value, not only in efficiency and productivity but in quality of life and satisfaction of users. The thoughtful design of today’s consumer apps are slowly disrupting the antiquated user experiences of our healthcare software and systems. Whether in a BYOD environment or provisioning mobile devices at scale, the return on investment is increasingly compelling and will continue to drive a desire and need to go mobile. Having a mobile strategy and a thoughtful implementation and scaling plan will be an increasingly essential part of running a healthcare organization.
[i] http://www.kantarmedia.com/us/thinking-and-resources/blog/professional-usage-of-smartphones-by-doctors-in-2015
[ii] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824151/
[iii] Cell phones and electromagnetic interference revisited [guidance article]. Health Devices 2006 Dec;35(12):449–56.
[iv] Unpublished data, BCH 2013.
