“Innovation” is one of those words that sucks up all the oxygen (Part 1)

Joshua Liao, MD: Thanks for having me. I'm a practicing internal medicine physician here in Seattle at UW Medicine. Outside of that, I spend my time working on two things. First, how we pay for and deliver healthcare. We have innovations like vaccines, tests, and other advances in medicine, but if we don't finance, organize or deliver care in ways that support people accessing those innovations, it doesn't work.

The other area I focus on is health decision-making. In nearly every healthcare intervention, the final common pathway is human behavior. We can deliver a service to a certain point, but then a patient – along with their loved ones, caregivers, and sometimes clinical teams – has to make a decision. I ask the question, “What are the decisions that people need to make in order for all our work in payment and care delivery to make sense?” If individual decisions aren’t aligned with larger goals, then all of that other effort could be for naught.

Joshua: I enjoy the mix of the three areas I work in. I love patient care. But moving back and forth between seeing the whole forest and then the individual tress, to use that metaphor, is edifying. Where the rubber meets the road is in how people make decisions. Those decisions reflect the sum total of all of the systems and behavioral architecture in play.

I prefer to think of these areas in terms of sequence. The healthcare payment and delivery models are the first pieces to have in place. I'm glad to hear you are thinking about those issues at Buoy. Second, once a model set up, then as a clinician I am seeing people within that model. But then I wonder how we design individual choice architecture. How do I optimize how people are making decisions? This includes before they walk in the clinic or hospital. How are they searching online? How are they using services to identify providers?

Consider the many delivery models now trying to focus on population health. These models are trying to wrap around services both in and outside of the clinic and hospital. Health care organizations and insurers say, "We're doing this model of care that supports population health by managing chronic conditions."

That's a laudable aspiration, but how are you going to implement it effectively? How does the EHR work within this model? What about triage or answering services? Are there pathways or protocols in place? What about how doctors talk with patients? These are behavioral pieces. Ideally, we practice within payment and delivery models that architect some of the decisions that are being made. It’s a joy when it happens.

Joshua: The thing I worry about is syncing up the intention and the execution of what we do in payment and care delivery policy, and decision-making. Sometimes we intend something very good, but the implementation becomes uncoupled from that. And it can do harm when they uncouple.

One example is that while there is a focus in healthcare on population health, there is also a concurrent trend toward individualized precision medicine. On one hand, we’re aspiring to manage individuals in the context of the populations they’re a part of. On the other, we’re trying to deliver exactly what each person needs via precision care – for instance based on knowledge about people’s genome.

Population health and precision medicine are both awesome ideas. However, I worry that in some ways they are inherently at odds. I don't know where the threading comes apart, but I worry that by pulling both ways, the proverbial threading could come apart and we may not hit the targets we want.