I've been asking Dr. David Ash a series of questions getting him to reflect on innovation in healthcare, and we're going to continue. I'm curious in your mind what enables new models to even have a chance to breathe. So, part of me think, it's well, when there's a payment model change and you're compensated differently. Now we have an opportunity, and I think from an innovation standpoint that's relevant because it says where do you focus or do you focus on what people care? And when payment models change, that gives you a new chance to, different people care about new things. So, two questions in there. One is, are there other models, types of approaches to healthcare that you think folks should be thinking about and the people taking this question should be thinking about, and other contextual elements like payment model changes that you think are the places to really pay attention. Yeah. No, I think it's a critical point. In the US, we are, have a certain kind of payment system actually, it's practically unique in the industrial world and so much of our activity in healthcare is driven by that. So, we can develop new approaches that can add value, but because of our payment system, we have a hard time capturing that value and so the incentive of various stakeholders gets misaligned with the creation of patient value. There are ways in which we can identify places to test our work and then, we've often done this with our own employees, where because we're the payer we can align the value capture with the value creation in a very efficient way, and hope that it works and then try to make the case sort of to the, I don't want to call it a market, but to the stakeholders who were involved in healthcare finance, that they should also change their thinking about this, not such an easy path to take. But I think there are many other platforms that are fruitful for innovation in the clinical world. It's funny I try to say this but healthcare is running far more on information systems than it used to. Everybody knows that and at the same time that people may pull out their hair, if they still have any or about electronic medical records. The reality is that by digitizing healthcare, by creating a single portal or at least, just a few portals where physicians connect or patients connect in their healthcare journey, you suddenly have a platform to change the environment in which healthcare decisions are made. So, I'm pretty excited about work that engages physicians, nurses, patients, caregivers within the sort of digital world of healthcare, nudges other kinds of activities from that are from behavioral economics or behavioral insights that change the work processes. I think again, we just talked about Mitesh Patel, and the studies of the work that he did to transform the decision making about prescribing generic versus brand name drugs with physicians was an incredibly great experiment in which by situating a piece of software or a software change within the journey of the physician, was able to tremendously transform or accelerate the move from brand name drug prescribing to prescribing of generic equivalents when they were available, when almost every other approach up to that point failed. As much as we want to complain about electronic records, they are going to be enabling for many of the innovation that we'd like to engage in. Sure, it allows you to create new interventions in the workflow which is a big deal. You know the fact that you chose hypertension also allows us to point out a couple other interesting things. So, one is the evolution of what you're testing from a hypothesis perspective, right? If I remember correctly, at the beginning of that journey, the question is can we get uncontrolled hypertensive to normal blood pressure. And you showed you could. And that was great, except it left then the next big assumption, untested, which is can we find the people that have uncontrolled hypertension and so now we can apply this new intervention that works. And so, it is really for me as I watched you and the team pursue that project, I saw this evolution of what is the big assumption? What is the core hypothesis? It changed, from can we get them to normal blood pressure? To can we find the people who need the intervention? Have you noticed that sort of, and how do you think about the, "Hey, what is the most important thing to be testing right now a problem." Well, it's so interesting you said that because it's not that you've got it backwards but we were aware of this, so you may not remember. So, we actually, when we started the hypertension project, everyone was always focused on ascertainment, how do we identify people with hypertension? And the reason is, this is the problem's because hypertension is symptom-less. You don't know that you have hypertension, it's not something you feel. And so, almost all of the work was, the thinking up at the time was the ascertainment or the case identification. And we decided, no let's actually, let's try the later problem first. If we find them, can we initiate management and get people's blood pressure down. We also, that later we have to think about how do we manage them long term? Because hypertension is a lifelong thing. So, we actually started in the middle, it was a deliberate thing and it was only once we realized what we can do this. Like, "Okay, now let's take a step back, how do we get people into the funnel." And simultaneously we're thinking about or how do we keep them going. So, but we started like, it's not typical to start in the middle, in fact we sort of stood the problem on its side and decided that one of the problems was, can you initiate management in an incredibly non-physician intensive way in a comfortable way and titrate to normal tension. If so, let's open the party. And that reflects one of the core principles of innovation, that I think we try to teach, which is get it right first and once you get it right, scale what works and not scale prematurely. And I think that's what- It would have been, not a disaster, but what if we had gotten, identified hundreds of people with hypertension, then we didn't know what to do with them? We would have had capacity constraints and all sorts, we would just had frustrated people who were no healthier than they would have been if we had never checked our blood pressure. So, the final point and, again just because you brought up that particular project, it does kind of allow us to talk a little bit about portfolio management. So, this is more oriented towards people who are building an innovation program or leading innovation in an organization. But the truth about hypertension management is if you're perfect, you probably don't save a penny in that same period. So, you get everyone to normal blood pressure, in that year you may not save a single dollar. Now five, 10 years down the line you've probably done more than you could do in any other intervention, but near term you might not see any savings or any gain from that, which implies this need for some kind of portfolio approach. Short term, long term, measurable economically versus mission driven, the right thing to do. How do you think about the portfolio element of what buys you the right to work on something that doesn't actually have any near term clear economic return? Yeah. No, it's a great point and it actually echoes a little bit of value creation, value capture aspect. I think everyone would agree that if we got everyone to normal tension, meaning eliminate their hypertension, the world would be a better place but we wouldn't realize that it was a better place or we wouldn't see those benefits until much later. We eat the fruit today from the trees that were planted a decade ago and we need to find a way to encourage that kind of investment. So, I think that within organizations that are going to make an investment in innovation, you're going to have to have some early wins and some early returns. I think that one of the most important things we did together as a team is focus on the health of our employees and some things that we could realize those returns, and here I mean really financial returns, early enough on to get some buy-in and to justify the sort of longer term investment. So, it's the early work that pays for the the orchards that are going to yield their fruit much later. First, you grow radishes, the radishes grow really quickly and you can eat the radishes and asparagus, it turns out takes a long time to grow. The very quick wins, more wins get that inertia and momentum going in and by the way, I'd be interested to hear you comment and just reflect on when you think about some of the programs that we've put in place here and think about the last cycle of innovation accelerators where you have someone leading, for example reducing re-admissions in liver population. And there are some chances that you can create, I think to celebrate faculty in new ways, do you think of them as meaningful? What are the things that you think have been working, if any, to get to raise the profile of people leading this innovation work? Yeah. No, I think it's a great point and I think, and you've emphasized it often, that things that get celebrated are the things that get emphasized, they reflect an institution's ultimate mission. And if you don't celebrate what's your ultimate mission, you're really out of, you're just out of alignment with yourself. I think one of the best things about the Innovation Accelerator Program that we set up is just that right. So, there's the substantive aspect of identifying a problem, working with the team toward its solution, rapidly testing alternatives, moving it forward as it graduates from from step to step. But equally important within all of that, is the idea that leadership of the institution sees those individuals, sees those individuals in fact in front of an audience. And so, pitching the idea, whether it's a shark tank thing, which is sort of adversarial or a pitch thing that's much more celebratory. Giving people an audience in front of the leadership, and actually helping the leadership see what often is the young talent that they wouldn't have seen. A few moments ago, you referenced seeing what other people didn't see. Remote sensing, to be honest, if you were the CEO of a major health system or is a dean of a large medical school, you don't actually know all your faculty that well, it's impossible. And many junior faculty or staff nurses or anybody in the organization, it might be a rare chance to be able to spend 10 minutes pitching an idea to the C-Suite leadership. That's an enormous plus and everybody wins from that. Everyone has an opportunity to be awarded one of these grants, everyone has an opportunity to succeed. Now, you've just created a mechanism by which they can get an audience with the leadership and it gives the leadership a chance to get an audience and actually to see what they are, and hopefully talented group of employees can do. I've been fascinated by, when we create a program, one of the things I'm fascinated by is who raises their hand, who basically reveals that they are one of these people who wants to come in and not only do great work, I think that's almost everyone, but actually change the way we work, and actually move it forward and innovate on the way we do our work. And so, some of these mechanisms reveal who are the people you should be paying attention to, I think in an interesting way. Well, I personally have learned a tremendous amount from working with you and I think it's actually a critical lesson when you're trying to transform healthcare, you need subject matter experts, it has to be with the clinicians. And so, as much as I've learned from you, I hope that the people who are taking this course take away your words of wisdom and learn from you as well.
