Dancing with the Devils: The Challenges of eHealth Vendors in the Canadian Market

Overview
EHealth vendors in today’s Canadian market face a predicament. They offer many solutions but have achieved relatively little in terms of the improvement of the health system and being directly linked to realizing better outcomes for patients. To really appreciate the situation, we need to define and understand innovation and what it should mean. Further, where our innovations hit the road, so to speak, with users – the issue of adoption – needs to be dissected and appreciated. To make this a bit more interesting, we will use the metaphor of disease and fold in a little humor. We’ll look at it this way: both vendors and users face a world where a number of e-diseases are prevalent. In the end, we need to consider thoughtful and potentially effective interventions to treat these diseases or at least transform them into more tractable forms.

The Predicament
Canada’s investment in eHealth is certainly into the tens of billions of dollars over the last 30 years. Each year, this expenditure grows by easily a few billion dollars. This includes the cost of equipment, networking and communications, software, corrective and perfective maintenance, human support of systems such as the Information Services (IS) departments, education and training, and so on.

About 20 years ago Erik Brynjolfsson identified the crucial issue of determining the increase in productivity secondary to computerization (Brynjolfsson, Erik. (1993). The Productivity Paradox of Information Technology, Communications of the ACM, December, Vol. 36, No. 12. pp 67-77.) He quoted Robert Solow, the Nobel economist, who said, to paraphrase: We see computers everywhere except in the productivity statistics (https://www.brookings.edu/articles/the-solow-productivity-paradox-what-do-computers-do-to-productivity/). Brynjolfsson eventually came to the conclusion that the effects of computerization were extremely hard to measure, especially in service organizations like health care. Further, the effect would be marginal at the scale of the GDP, frustrating a macroeconomic approach to measuring productivity. So, one message is that it may be extremely difficult to measure the effect of eHealth on the health
system. At the very least, however, we can currently state that there is some, but very little, evidence of any substantial, tangible effects.
Particularly, with regard to the impact of eHealth on patient outcomes, virtually every study has shown that, at the very most, its effect is minimal, or, as one article in JAMA put it, “subclinical”.

During this same 30 years, medical interventions have dramatically improved, and significant effects have been seen on morbidity and mortality. There has even been significant improvement in the process of health care, through interventions like care paths and inter-professional discipline, for example in the surgical suite. So we have indication that medical care has dramatically advanced, while all of our technological innovations in clinical software applications have had little quantifiable impact.

Innovation
Clearly, what is needed is real innovation. All of us have seen specific innovations and watched their rapid dissemination and almost passionate acceptance. There was the explosive proliferation of spreadsheets, fax machines, the Internet itself, and, more recently, the smart phone, at least once their value was realized. How do these things differ from eHealth and why have we not seen a virtual electronic tsunami in health care?

Without deeply analyzing the nature of innovation and how it pervades an environment, we can at least note a few characteristics of innovation:

First of all, innovation seems to have a right moment. There must be a latent need and perhaps earlier approximations to satisfying this need. It also seems to have an ignition point, just the right “temperature” for it to happen, like a critical mass of existing fax machine owners.

Secondly, the innovation must be capable of doing almost anything (within its area of application), anywhere, anytime, affordably and easily. This describes why the Internet detonated and quickly spread its shockwave through our society. It also explains the popularity and success of online education and, within our field, of telehealth programs. Regarding the latter, recognize that this technology can be used to deliver educational material, support a mental health encounter, enable a large group meeting and medically enfranchise anybody regardless of location and time. It’s a veritable Swiss Army Knife of capabilities.

A lot of people in the eHealth inner circle claim innovation. But it is very difficult to find applications that have ignited to the point that we cannot do without them. One big issue is usability. One industry hack said many years ago that a system “should be so easy to use that there is no reason not to use it”. How many systems are like that in eHealth? Many of our systems are changes in the medium, like that for recording medical records, without a change in the message – no special value is added. So there are few applications that are true innovations by almost anyone’s definition. Why is this true and what can we do about it?

Perhaps most importantly, innovation should cause a tangible, or even measurable positive change in what we do or in the way we do it. Innovation is actually more a result than an input. Innovation is an effect and it has a life of its own.

Disruptive Innovation
Perhaps it is worth a few words about disruptive innovation, a concept first put forward in the Harvard Business Review. A disruptive innovation pushes out preceding reality. It is so functional that it changes the very nature of the business we do, like shopping online did.

Disruptive innovation makes things dramatically easier. Think of Airbnb and Uber. They make finding a vacation home away from home or getting access to urban transport far easier than anything before them. Perhaps we should also include autonomous cars in this category, because there is significant evidence that they will dramatically reduce road fatalities and can be introduced in parallel with the driver. Most certainly, the Internet of Things (IoT) and Artificial Intelligence are in this class. As these both gain broader application and refinement, we will find ourselves interacting with a fully connected interventional network of devices, diagnostic tools and intelligent analytics.

Sometimes, disruptive innovations replace expensive, extremely functional systems with less expensive, more focused systems. Other times disruptive innovations are themselves highly functional. The Internet allows us to modularize but integrate these two possibilities by having many kinds of ‘things’ all networked together and functioning as a single system.

Given what we said so far, perhaps the Internet itself is the most disruptive and most innovative artifact of humans so far. It enables virtually everything we have presented and serves as the platform for technological evolution.

Adoption of Innovation
Disruptive innovations grow tentacles that reach out and grab us, making adoption virtually automatic. They entrain the creativity of users in further developing their applications. In health care, we often face great travail in attempting to get users to actually adopt and employ systems. What we develop lacks these tentacles!

Let’s look at some examples.

Disruptive Innovation in Health Care
One favorite, potentially disruptive application, is patient engagement solutions. Hundreds of companies have developed products to serve the patient in capturing personal health information and making it available to his or her care provider. Unfortunately, most of these companies have failed, and patient engagement solutions like personal health records are still not pervasive, and are “untethered”, not connected to the care providers’ systems. What has become pervasive is the plethora of personal health apps. However, adoption and sustainability of these apps continues to be a challenge for this market.

Perhaps another example is genomics. Over the last 20 years, we have succeeded in mapping the human genome, once considered to be the entrance key to the paradise of ideal health care. The idea was that, if we determine the genetic makeup of a person, we could personalize our interventions and perhaps even correct genetic mistakes. This has certainly been a significant innovation, but still has a long way to go before it delivers on its promise.

So, it is possible that the equivalent to the power of the Internet in Medicine is the power of genomics in health care, but that is still over the horizon. ‘Personalized’ or, ‘precision’ medicine is happening, but it’s more of a slow burn than a detonation.

There are countless other examples of technologies, of new delivery modes and of processes enabled by technologies. However, when it comes to eHealth, we seem to be dealing more with the equivalent of diesel fuel than Witches Brew or C4!

The key is to ask the question: how many of these innovations are crucial today for successful patient care and, without which, the golden promise of universal, quality care can simply not be delivered?

So what does that have to do with eHealth Vendor Challenges?
Perhaps it is a common human characteristic, but we all seem to be programmed to fear, avoid, and run away from innovation. Innovation seems to fascinate us intellectually, but when it comes up against us or our jobs, the model seems to be NIMBY (Not In My Back Yard).

To illustrate the challenges that vendors face, we can view them as ‘virtual disease states’ brought on by environmental factors or psychosocial toxins. The disease states we will enumerate are both the result of dysfunction and they are the causes of dysfunction in the health industry. These dysfunctions have their etiologies in vendors, in the health care clients of vendors, in the government that is involved in stimulating, managing, manipulating, frustrating, or interfering in the industry, or in all of the above.

The Virtual Diseases
Let’s examine the spectrum of Virtual Disease (VD?) prevalent in our industry:

Hypengiaphobia: (from the Greek hypengyos, meaning
‘responsible’)
Hypengyophobia or hypengiaphobia is the fear of responsibility. The hypengyophobic person is often self-centered, self‐indulgent, and neglecting of all responsibilities at the expense of others. This disease has the characteristics: (1) avoidance of and/or lack of accountability, and (2) project failures and absence of valued results.

Centophobia: (from www.phobiasource.com)
Centophobia is the fear of new ideas. It is the persistent and abnormal fear of anything new. Its symptoms include: reluctance to consider new ideas, or the ideas of others, or disinclination to break from established thoughts and ideologies. Centophobia stifles creativity and can instill a fear-of-failure environment that burdens the system with the obsessive need for validation through expensive pilot projects and risk aversion strategies.

The impacts of this disease include: (1) technology advances are met with cynicism, skepticism and disbelief, (2) human culture and ideas do not advance as quickly as our technologies, and (3) very few significant technological innovations in health care are adopted.

Hyperprocurementism: (we made this one up!)
Hyperprocurementism (on the spectrum of OCD) is the state in which unreasonable and pragmatically-impaired rules and regulations are applied to the purchasing evaluation process. Often implemented as a reaction to industry scandals, these rules tend to increase the cost of procurement both for the buyer and the seller, with no evidence of increased value for money spent.

This disease results in: (1) failed procurements, (2) the flight from quality to the lowest-cost solution, (3) vastly increased consulting and legal fees, and (4) disengagement from vendors.

Technophobia: (from the Greek τέχνη technē, ‘art, skill, craft’ and φόβος (phobos), ‘fear’)
Technophobia is the fear or dislike of advanced technology or complex devices, especially computers.

The disease has profound effects: (1) a market that fears technology advances is a market that remains dormant and unprogressive – health care exhibits these traits at times, (2) failure to adopt advances in technology excludes agencies from reaping the benefits of efficiency and quality improvements, and (3) it causes health care to realize only minor technological advances over long periods of time resulting in marginal adoption rates and minimal progress.

Epistemophobia: (from the Greek έπιστήμη, knowledge) and φόβος (phobos), fear)
Epistemophobia is the fear of having knowledge. In our context herein, it refers to the environmental knowledge associated with a particular product or solution in question. It is often associated with Hyperprocurementism, whereby communication (thereby ‘learning’ or knowledge) is prohibited between buyers and sellers. As a result, buyers become ill‐informed about the current state of the market and become reliant on their own ignorance about a particular product or solution they seek to acquire.

The effects of this disease include: (1) lack of knowledge about what or how to purchase, (2) lack of buy-side industry knowledge, which impacts general industry innovation, (3) exacerbation of vendor frustration, and (4) impossible head winds against new entrants to the marketplace.

An illustrative story:
“There once were four people named Everybody, Somebody, Anybody and Nobody.

An important job had to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it! Somebody got angry about that because it was Everybody’s job. Everybody thought Anybody could do it and that Somebody would do it. But Nobody realized that Everybody thought Somebody would do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done.”

https://www.lollydaskal.com/leadership/story-everybody-somebody-anybody-nobody/

So What is a Vendor to do?
Given these prevalent diseases, the vendor has few options. Perhaps the most devastating option is the decision to leave the Canadian healthcare marketplace either by focusing made-in-Canada innovations on more receptive markets, or by abandoning all efforts to sell an established solution in Canada. Another is to consciously put its business at risk. Virtually all vendors in the eHealth marketplace have to decide if the potential outcomes – winning contracts and maintaining a satisfied client base – are worth the enormous cost of playing the game.

Figure out the Treatments!
Another option, is to take a nearly medical approach to the eHealth market. This involves tabulating its challenges, labeling them, finding potentially effective interventions, and, if not curing them, at least ameliorating them.

So let’s look again at our list of the market’s virtual diseases:

  • Hypengiaphobia (Fear of Responsibility)
  • Centophobia (Fear of New ideas)
  • Hyperprocurementism (Fear of Purchase)
  • Technophobia (Fear of Technology)

It seems that our prognosis is not good unless we deal with them. What can we to moderate or cure them?

The Treatments
Some might think it is important to examine each of these diseases and develop ‘pharmaceutical specifics’. However, they are all closely related and can be addressed with a broad-spectrum therapy. The medicine isn’t really very bitter and we hope that a little sugar will help it go down easier. Remember that the ‘patient’ is both the vendor and the client.

It is important to consider the implications of these diseases and the resulting environmental, educational and psycho-social impacts they are having on our industry. In more general terms, this group of diseases have contributed to an increasingly complex procurement and deployment atmosphere that has had dramatic (and sometimes mortal) implications on our eHealth industry.

There is a clear need for interventions to manage these diseases and an even greater demand for clear and concise care paths to enable the reinforcement of treatment and the evolution of best practices and improvements. As it stands today, the following “treatment protocols” should be considered:

Here is what we suggest for both vendors and clients:

  1. Engender a culture of ‘positive failure’. Make it so that carefully undertaken risk can survive failure, if not on the first try, then thereafter.
  2. Set focus on the long term payoff. Build, in the short term, the foundations for the long term, and see these as ‘infrastructural’ investments (think highways and bridges, not cars).
  3. Establish leadership accountability at all levels in the organization, not just the most senior. Think of having a team of leaders.
  4. Foster a culture of adaptability and embrace managed risks to achieve significant and valued change and outcomes. Think of paradigm shifts and remember that when it comes to paradigms, shift happens!
  5. Concentrate on evolving the current state to the new state rather than clinging to the current state. Don’t just think about what is; dream about what can be!
  6. Set clear objectives and a co-operation plan, where win/win and reward/reward are the catchwords.
  7. Leverage all possible internal and external sources of knowledge and experience.
  8. Carefully evaluate vendors, with a focus on a genuine trusting partnership and organic collaboration and co-operation. Learn about and deeply understand what they offer.
  9. Establish and continuously strengthen engagement between health providers and industry. Think ‘sine qua non’ (without which, nothing).

Some Suggestions for the Vendor
What is a vendor to do in this challenging situation?

We suggest that the vendor must shoulder strong leadership of the overall purchasing process, not to guarantee the success of the vendor, but rather to guarantee the success of the client.

It is crucial that the vendor does not sacrifice its standards, whether they be moral, ethical, legal, economic or technical, even if winning demands that sacrifice. Sticking with the good will ultimately deliver the best outcomes. Remember that winning isn’t always the best result and that there will be another time, another place, the same or another client and another opportunity.

Regardless of the effort the vendor makes, things can go wrong. Sometimes what the client wants is not what the client needs and this might be a time to disengage. Do not be afraid to ‘fire’ a customer!

Other than that rare time when disengagement is the only way to get the fat out of the fire, do everything in your power to engage the customer even though the rules and their application are difficult.
Working in the eHealth marketplace is all about relationships. The vendor must be a relator. That’s sort of like a ‘realtor’ where “location, location, location” are the three rules. However, for a ‘relator’ its “relation, relation, relation”.

Really work on and work with the rules of the marketplace, those of government, and those of the client, but make the application of the rules practical. The rules are not a theory; they are practice and they must be applied in a practical way.

Perhaps one other thought: there are no product-only opportunities. Services are crucial! All products must have at least an ‘enteric coating’ of services, but services are at least adjuvants, if not the real therapeutic. The vendor must deliver a complete and effective intervention. Expecting a product-pill to be a cure for healthcare inefficiency and ineffectiveness is wishful thinking. Like in human health, a lifestyle change is what works, and that must be the vendor’s deliverable!

So, the final words to all vendors: Fight against frustration. This is a tough marketplace, no ifs ands or buts about it. Entering this marketplace with rose-colored glasses while listening to joyful music delivered by earbuds works just as well as it would for first responders to a house fire. There is a desperate need for your capabilities, and parts of health care are in a crisis state. You have to have your heart and your mind ready for this. The alternative is spending years in recovery from post-traumatic distress disorder!

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