Dr. Bill Crounse and David Lubinski Explain How Adaptive Design Can Improve Health Care Systems

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Microsoft Corporation

Never before have we had the technology and devices that can actually giveclinicians a tool that improves safety and quality, but also makes themmore productive.

David Lubinski Managing Director, Microsoft

Bill Crounse, M.D. Global Healthcare Industry Manager Microsoft

HCT: For a long time people have been talking about how technology can improve health care, but there is a lot of resistance and slow adoption. Why is it paramount now to adapt old, existing technology to address new industry issues?

Bill Crounse: In health care, we have a lot of old legacy information technology in place but we also have a lot of exciting new technologies. In fact, I think that is why all of this is so compelling at this point in time – I think we literally have what I call “the perfect storm” brewing in health care information technology. Never before have we had the kind of robust information worker solutions that are so needed by health care workers. Never before have we had the kind of adaptive and intuitive user interfaces we can offer today. Certainly we have not had the mobility and the kinds of devices and the data input options that can be brought to bear; nor have we necessarily had the interoperable means of bringing together disparate systems in a way that in some cases allows health care organizations to keep older technologies in place and still use them very effectively, while also allowing them to add some of the newer technologies to the mix – all of this at a lower total cost of ownership than they have experienced in the past.

Dave Lubinski: We have crossed an important threshold for the way users interact with information tools. We are now seeing that this enables dramatic levels of adoption to occur. People have said in the past that the reason adoption has been slow is that doctors or nurses won’t use new tools; but what we find is that nurses and doctors are the most sophisticated users of tools – very advanced medical equipment that requires high precision – and they use them very well. When you look at information technology, people ask if there is really resistance from the end users. Well, we maintain that the users have not had the opportunity to use tools that are easy, adaptive, and intuitive. Tools have matured to the point where they are useful and productive, and users can interact with them in the same way that businesses do, for personal reasons – like booking an airline ticket or dealing with their financial institutions. Doctors and nurses now have access to the same useful, intuitive interfaces that they use in other parts of their personal and professional lives; as a result, they are saying that this makes sense, this works.

HCT: Hospitals face many challenges and are already struggling to make ends meet. It must be difficult for them to focus on the latest technological advances. Tell me how the promise and opportunity of IT in health care will be achieved through emergent processes and adaptive design.

BC: From a physician’s perspective, Dr. John Kenagy and his colleagues at Harvard have written about adaptive design that all too often has been missing in health care IT; the perfect has been the enemy of the good. Traditionally we have tried to develop systems that are all encompassing – that try to anticipate every possible business or clinical problem that could ever exist. They become so expensive, so complex, and so impossible to implement that by the time you even get close, the technology has become outdated. The flip side is taking a more adaptive design approach to these solutions – you look at a particular business or clinical need and use these latest, greatest tools and solutions to tackle that need as it exists today. You can do it very quickly, very inexpensively, and with a fair amount of flexibility, so that once you have solved your problem, as it begins to evolve into the next challenge, you can quickly respond with another cycle, continuing that adaptive process.

DL: We have two case studies that illustrate both of these questions in a very powerful way. Washington Hospital Center faced the challenges of limited resources, legacy applications that were not going to be replaced, and high demand among clinicians for better information for clinical decision support. They found that by using the tools that we offer, they were able to pull information out of the legacy systems, and using .NET as a framework, actually present it to the end users in a way that was intuitive and easy to use. They were also able to build a clinical data repository that now exceeds 13 terabytes in size and that didn’t force the replacement or the change of any of those legacy applications. They found this was an exceedingly cost-effective way to deploy a solution.

BC: Another great example of this adaptive design process is NewYork-Presbyterian Hospital. One of the real benefits of adaptive design and some of the new tools and interfaces that we have today is you can create something that literally requires no training for the end user to put into practice. A classic example of this case was a nursing triage problem in the emergency room that needed a better system than just paper for properly determining a patient’s needs. To do this, NewYork-Presbyterian Hospital worked with a Microsoft partner, Standard Register, and one of our solutions, InfoPath, to create an electronic form that pretty much mimicked paper, but allowed the nurses to use wireless Tablet PCs, a pen to enter data in a way that was familiar to them, and a form that was inherently familiar because it was similar to the one they had been using. They could capture all of the data electronically and do all of this using adaptive design and extreme programming in basically a four-week cycle, from the time the problem was identified until the solution was developed, at a very low cost – $50,000.

HCT: What are some of the challenges for implementing industry health standards and schemas?

BC: Well, there are a number of new governing bodies involved – standards and schemas are incredibly complex things. Having said that, the good news is, again, with this perfect storm in health care information technology, there are some things going on that look promising. At the government level, there is increasingly a call for industry standards, and with the appointment of Dr. David Brailer to the newly created role of National Health Information Technology Coordinator, we have for the first time a centralized power that can really drive this process. Also among providers, there is increasingly a move toward standards – so that we will get better interoperability between whatever systems we put in place. The classic example is the work pioneered by Massachusetts Medical Society, working with American Academy of Family Physicians, the ASTM, the AMA, and more recently the American Academy of Pediatrics, and some of our technical people from Microsoft to create a continuity of care record. They have all signed on to this initiative, and with technical assistance from Microsoft, are working to develop a continuity of care record. That is a standards-based minimum data set that will identify a patient, their demographics, and a brief medical summary with important information such as their allergies, medications, list of diseases, or their other health problems. In a highly portable, very secure format, again using industry standards such as XML, they can transport this data between the silos of information that exist today in health care so that when a patient moves from one system to another, their health record can move with them, or, it could simply be stored on a storage card or printed out on paper for them to take with them. This is in line with the move toward electronic medical records.

DL: This is a really critical area. One of the reasons that standards have yet to be adapted is the costs involved. Bill focuses on providers worldwide and I’ve worked with life sciences and health ministries worldwide, and all customers complain about the cost to integrate and interface systems. That cost is often a major component of their budgets and it is not a very productive one.

We are finding that user tools are becoming more intuitive and adaptive and, as a result, more useful. We can use industry standards and XML, and build those into our basic platform – like Office, like BizTalk server. We did that with the HIPAA accelerator. We took the 12 mandated transactions to support the HIPAA regulations and we just built them into BizTalk server, which allowed customers to quickly and inexpensively support those 12 HIPAA transactions.

We have done the same with HL7. Bill talked about a very exciting project that takes it one step further: It supports the collection, management, and communication of the continuity of care record, which is also a part of the standards work under ASTM. And our objective at Microsoft is to help our customers deploy these standards at the lowest possible cost in the least complex manner, and hopefully in a self-sufficient deployment. So the customers can learn to use these tools themselves, and, working with a partner, can deploy them very cost-effectively. It goes back to Bill’s point about the perfect storm – the technology is finally going to deliver on the promise.

BC: The standards organizations, Massachusetts Medical Society, and the continuity of care record again illustrate the idea of adaptive design where bodies are coming together. Instead of coming up with the perfect data set for all of health care, let’s get started on this minimum data set using commodity software and good standards, and create a living document that gives us a minimum data set that we can put into use today. Then as we refine and expand the standards, this document can grow.

HCT: There seems to be an increasing amount of interaction among standards organizations such as the National Council for Prescription Drug Programs (NCPDP), Digital Imaging and Communications in Medicine (DICOM), the clinical messaging standard (HL7), and the transaction standard (X12). Would you say that collaboration is increasing?

DL: Absolutely. Not only is collaboration increasing, but I think that innovative companies are finding that there is no advantage in taking proprietary approaches to moving information around. The competitive advantage that companies can bring to the table is being able to support the way clinicians deliver better health care – safer and more productively. That’s where they stand the chance to really shine above their competitors. How you move information around with the standards that you mentioned, whether that’s DICOM, or NCPDP, X12, or HL7, is not the way to compete and win over your competition in the same way that the automatic teller network, that is now global, does not provide an advantage of one bank over the other. Banks have to compete on how well they serve you as a customer. In the same way, we see these innovative software companies needing to compete on how well they support high quality, very safe, very productive health care. That’s really an exciting thing. Our job at Microsoft, of course, is to try to help those developers achieve that kind of interoperability and integration at the lowest possible cost, and it is something that we focus a lot of our energy on. Canon Medical and Digital Healthcare, both partners of Microsoft, collaborated to integrate the standards that you mentioned, including SNOMED. Because they used a .NET framework again, they were able to bring DICOM images into a very intuitive user interface that enabled analysis for diabetic retinopathy in a noninvasive way at a very low cost. There are approximately 20 million diabetics who are at risk of losing their eyesight, and Canon Medical, working with Digital Healthcare (a 25-person company in Cambridge, England), were able to collaborate and do in one year what other companies have been trying to do in five or six – all standards based.

BC: From the physician’s perspective, from screening patients to retinopathy to looking for pigmented lesions on skin, this ability to document these kinds of things in a visual way and track them over time is extremely important in health care.

HCT: Tell me about some of Microsoft’s solutions for improving productivity, safety, and quality.

BC: We have some wonderful stories to tell, particularly in light of the new release of the 2003 edition of the Office system, and work that is being done by some of our leading partners, such as Eclipsys, NextGen, Scan-Soft, Allscripts, Amicore, and others who are embracing this concept of taking what is very intuitive commodity software and wrapping around it the industry-specific content and rules that health care providers need to provide quality care to their patients.

Even before the release of Office 2003, we were seeing some remarkable stories that were highlighted in our most recent MSHUG awards. Around the country, providers and small health care businesses were using tools like Office, Sharepoint, and Outlook to run their business or capture their health information. It is this kind of innovative, pioneering work using contemporary, easy-touse software and tools that is exciting.

DL: We are finding that the tools people have become very familiar with, such as Outlook and Word are enabling rapid adoption of powerful applications that use the same look and feel. This is especially true with InfoPath, which leverages the power of XML through a way in which the user is already comfortable. Because of this, customers are able to adapt and apply in really exciting ways and therefore they require little to no training. That goes back to your point earlier about adoptability. We are seeing companies – Allscripts, Eclypsis, Stentor, Merck, Pfizer, and now WellPoint, with their recent decision to use the Microsoft-based e-prescribing solution – using all of the learning that people have invested in as a base for interacting with computers; and now they can apply that to solving clinical problems. It is important to note that Microsoft’s role is to help these partners leverage the platform. In many cases, we will go out and build some technology basically to illustrate what can be done, and then we work with those companies, like Eclypsis, Stentor, and Allscripts, on how to use that as a part of a commercial line of business application.

We know that we are good at building that core platform. Bill has two case studies that have been developed that solve the same problem – NewYork-Presbyterian Hospital, and we did the same level of work with a customer in Germany, Ingolstadt Hospital (Klinikum Ingolstadt), each using different languages, different currencies, and different funding systems. One is very socialized and centrally managed, and the other very market-based – same technology. That is pretty powerful when you can take the research and development that we invest at Microsoft (which will exceed $6.8 billion this year) and leverage that across a global market.

BC: That this is happening is not too surprising to me. Microsoft is well known for their great information worker tools and their 450 million users. The work that clinicians do is literally the definition of information work. When I think back to what I did every day as a physician, I examined patients, I interviewed patients, I looked at lab and imaging data, I conferred with colleagues, and then I had to document all of that in exquisite detail. If that is not information work, I don’t know what is. And what makes our information worker tools even better is the communication and collaboration capabilities of our solutions. And again, when you look at health care, nothing is more important than excellence in communication and collaboration. That’s another value these tools bring to health care.

HCT: Is there much reluctance from doctors and nurses to adopt new technologies? Do you think they recognize the benefits in quality and patient care?

BC: It’s a misconception that doctors fear technology – after all, who were among the first adopters of cell phone technology? Doctors. And in our health care settings we are surrounded by advanced diagnostic and therapeutic technologies such as MRIs, CT, and Pet Scans. It’s not that doctors fear or loathe technology, but it must better serve patients.

It must be easy to use; adaptive; it must make doctors more productive; it must solve a business need, or dramatically show that it does indeed improve the safety and quality of care. And that is where we started in this perfect storm. Never before have we had the technology and devices that can actually give clinicians tools that improve safety and quality, but also make them more productive. That’s been a missing ingredient – the productivity issue – where bringing these devices and technologies into a clinical setting often slowed clinicians down. But now because of the mobility, the intuitive user interfaces, and the data input options, much of that is being solved.

DL: I have a daughter in medical school who wants to be a family physician. I don’t know how much time you have spent looking at the physician perspective on practicing medicine, but it has gotten pretty tough. It has gotten hard to earn a reasonable living and recoup the investment of what it takes to become a physician in North America and deal with all of the regulations that we talked about, including reclining reimbursements and a very litigious environment. When physicians like Bill talk to their peers and colleagues worldwide, they are looking for ways that they can deliver great health care that is safer, that is more productive, and quite frankly puts pleasure back into the practice of medicine.

They are not averse at all to using tools. Having said that, they also don’t want vendors wasting their time. They don’t want someone to come in with approaches that require more effort or that introduce more complexity to their practice operations. Physicians need solutions and tools that are easy and intuitive, that don’t require massive changes in workflow and business process so that they can actually serve more patients in the time they have or better serve the patients they have, in the time they allocate. When you can deliver tools that are based on intuitive user interfaces like Microsoft Office or InfoPath and basic Web forms, most physicians are eager to use them. We find that they are exceedingly interested in using these tools in their daily practice. Frankly they come back with many suggestions on how to make it even better. That’s really the point that Bill raised at the top of the interview. Adaptive design only gets you started with how to build meaningful applications – it does not end. So as soon as you begin, you immediately start collecting feedback. Now here is the dilemma: Is the technology that got you started able to respond to that adaptive feedback? We believe at Micro-soft that our platform does that. It allows you to continue to adapt and innovate and add more value that is driven by the user. It is a very powerful dynamic. As Bill said, the perfect storm is here. You can go to Best Buy and walk out with the basic building blocks of what it will take to do very powerful things.

BC: Affordability is a critical issue for today’s physicians. A lot of the resistance to information technology over the years has come from the fact that the solutions offered have been too complex or too expensive. Early adopters frequently just gave up or felt let down. So they are naturally a little leery about getting burned again. Lower cost and greater value are extremely important and I think the solutions that we and our partners are bringing to market wrapped around some of these terrific commodity tools, truly make them affordable. So you add the affordability, the adaptability, the intuitiveness, the mobility, the data input options, and we have a winning combination.

DL: This is the second year of this project. Physicians like Bill are joining Microsoft because we think that the education of the marketplace is important. I just want to reinforce the importance of the work that you are putting into this; it is not just another periodical or another shot at getting some mind share. We really think that the critical education about what the technology can now do is a very important task that we have in front of us – what you are doing here is a big part of that. We want to say thanks.