When it comes to new technology, Christensen’s model of disruptive innovation can be fairly well understood.
New markets with added value are created by the introduction of a new business model (not just a new technology), which disrupts the existing market. The transistor radio is a classic example of a disruptive innovation. (1) However, when we discuss a system built upon process, like healthcare, the notion of defining disruptive innovation becomes more challenging. Perhaps O’Ryan’s description of constructive disruptive innovation becomes more relevant. In this construct the goal is to create a model that is less expensive but more creative, more useful, more impactful while still being scalable. Constructive disruptive innovation combines ‘off the shelf’ technology/ideas with the novel and original to improve the process. (2)
It goes without saying that the field of spine care is replete with variation, waste and misuse. Direct costs for spine care have risen almost exponentially over the past three decades, while indirect costs (those typically associated with lost productivity) have followed suit. (3) In spite of these exorbitant expenditures on spine care, our outcomes as measured by disability are worsening. Many investigators have identified spine-related disorders as one of the costliest health conditions society faces. The need for change is obvious, but what change and how do we get there?
We know that spine care invites innovation (just consider minimally invasive spine surgery) but is spine care ready for disruptive innovation? Is constructive disruptive innovation a better alternative? A key point to remember is that innovation by definition is considered a novel process that brings together various ideas. Disruptive innovation involves a business model that, while disrupting the existing market, adds value. And constructive disruptive innovation brings together ‘off the shelf’ components with novel and original components to again, add value and be scalable. The real challenge is to bring together each of these concepts in a palatable, implementable way. Some key elements of change needed to ‘constructively disrupt’ with innovation include:
- A focus upon the patient’s first point of contact with the healthcare system
- A continuum of care pathway that is patient centered, evidence based, cost effective
- Standardized assessment strategies for spine disorders with classification/stratification model
- Enhancing communication, particularly with EHR, to help drive behavioral change
- A focus upon relationship centered leadership and healthcare – achieving relational coordination among key stakeholders: mutual respect, shared goals, shared knowledge, effective communication
- Community outreach of healthcare system
There is growing evidence that the ‘first touch’ provider is a significant determinant of subsequent procedures and costs. Darlow noted that the language used by primary care physicians on the first visit can positively or negatively “influence the beliefs of patients for many years.”4) Another study has shown that ‘first touch’ decision of ordering an MRI too early in a care plan can lead to worse outcomes and significantly higher costs. (>$12,000 per episode). (5)
Keeney et al demonstrated that even with control for case severity, those back pain patients whose first contact is a chiropractor are substantially less likely to end up with spine surgery compared to first touch of the episode being with a spine surgeon (with chiropractors seeing about 35 percent of all spine pain as first touch provider. (6) Primary care physicians typically see 40 percent to 50 percent of spine pain as the first touch provider. Craig Sammit, MD, the CEO of Dean Clinics, reports that while primary care physicians only account for 6 percent of overall healthcare costs, they are responsible, directly or indirectly for 80 percent of the remaining 94 percent of costs. (7)
Consequently, providing these first touch providers with a continuum of care pathway that is patient centered and evidence based is imperative to effective and efficient care. Paskowski et al published their experience with a spine continuum of care pathway which focused upon the first touch provider. (8) While the care pathway can breakdown ‘silos’ of care within an organization, the pathway can be expanded to a platform (9), reaching out to the community that the healthcare organization is serving. But more is needed: a focus upon relationship centered care and leadership has been shown to not only improve job satisfaction, but also improve clinical outcomes. (10) This approach has been referred to as relational coordination: shared goals, shared knowledge, mutual respect and communication that is timely, frequent, accurate and problem solving. Communication can be enhanced with electronic health records.
By combining the attributes of focus upon first contact providers, including non-physician providers, continuum of care pathways, relational coordination, enhanced communication tools (11) and community involvement, a model of constructive, disruptive innovation could evolve that truly will change healthcare, at least for spine, for the better.
References:
Christensen CM, et al. Will disruptive innovations cure health care? Harvard Business Review September-October 2000.
O’Ryan D. Constructive disruptive technology. http://en.wikipedia.org/wiki/Disruptive_innovation
Brook MI, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299(6): 656-64.
Darlow B, et al. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine 2013; 11(6).
Webster BS, et al. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. Spine 2013; 38(22): 1939 – 1946
Keeney BJ, et al. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington state. Spine 2013.
Sammit, C. Living in the world of accountable care and reform – lecture to Massachusetts Medical Society 2012 http://youtu.be/To7WkfTuWII
Paskowski I, et al. A hospital based standardized spine care pathway: report of a multidisciplinary evidence based process. J Man Physio Ther 2011; 34(2): 98-106.
Ventura J, et al. From guidelines to pathways to platforms: improving patient care. Becker’s Clinical Quality and Infection Control. Feb 18, 2013.
Gittell J. High Performance Healthcare: using the power of relationships to achieve quality, efficiency and resilience. 2009 McGraw-Hill.
Suchman A. Organizations as machines, organizations as conversations: two core metaphors and their consequences. Medical Care 2011; 49(12):S43-48.