As a new chair of the Department of Biomedical Informatics at the University of Utah, I wanted to bridge the gap between informatics researchers and delivery of innovation in the healthcare organization. My solution to this gap was a seed funding program for applications that demonstrated a collaboration between a researcher and an operational partner, with the CEO of the hospital selecting the most important projects to work on. We funded 8-10 projects over 3 years. A few papers were published, but not a single project was implemented and the effect on collaboration was minimal. How did Helen Bevan know about my hard-earned lesson:
Countless small scale changes can be a thousand flowers blooming with no overall impact.
In contrast, the ReimagineEHR initiative that we started after this experiment is a thriving collaboration between researchers, clinicians, and operations. Ken Kawamoto and Guilherme del Fiol are the academic leads of ReimagineEHR, which aims to:
apply research methods and innovative technologies to design EHR-integrated tools and information displays that enhance a user’s experience, improve patient care, and deliver personalized, value-driven, and patient-centered care for individuals and populations.
ReimagineEHR has implemented over 25 innovative applications across several healthcare delivery systems and is a thriving research program. It illustrates the virtuous cycle that can occur when healthcare delivery goals are aligned with research incentives in a system-wide framework.
Clinical and operational needs drive the selection of projects,
Research grants are more successful because of the ability to implement and evaluate in multiple real-world settings, and
Research funding enhances the operational work through additional staff and funding for evaluation and other more exploratory activities.
Ken Kawamoto questioned my idea of seeded projects as the solution to the research-practice gap, partly because of misaligned incentives. That is a point made very thoughtfully by Easterling, Perry, and Miller when diagnosing why the LHS concept has had slower uptake in academic health centers in the US. They list the following categories of LHS scholarship as particularly challenging to implementation in an academic setting:
Conducting studies that focus explicitly on critical patient-care issues facing the health system itself (as opposed to larger research questions)
Conducting studies where clinicians and system leaders are directly involved in specifying research questions, designing studies, and formulating the interventions to be tested
Conducting studies that have short turnaround times in providing answers to health system leaders
Translating study findings into practice changes within the clinical enterprise (as opposed to simply publishing findings in the scientific literature)
Engaging patients, families, and other stakeholders in designing and carrying out studies, as well as interpreting and translating the results.
An individual researcher or clinician will find it difficult to overcome system-level barriers that require changes on the academic and healthcare side. Individual hero projects that persist against the barriers won't transform the system. We need system-level innovation structures to align incentives and processes.
How Stella Saved the Farm is a parable that illustrates the need for alignment between work focused on predictability (business as usual) and work focused on exploration. Without nurturing and coordinating both types of work in a system, the demands of everyday work will overcome new streams of innovation.
A publication about ReimagineEHR assigns success of this multidisciplinary research-practice initiative to the following system-level structures and processes:
creating enterprise-level governance to select the most important projects to work on
establishing a world-class team
creating shared infrastructure to support individual innovations
developing and implementing innovations with high anticipated impact and a clear path to adoption
incorporating best practices and standards
maximizing synergies across research and operations and with partner organizations.
According to Easterling and colleagues, some academic health centers are finding ways to integrate the LHS paradigm into their research enterprise by funding researchers to address the health system’s priority issues, shifting the criteria for promotion and tenure to support those researchers who choose to focus on the pressing issues facing the health system or establishing institutes dedicated to LHS research.
Bill Bannear summarized it well:
We need to stop trying to design the solution & instead design for the relational conditions that enable the emergence of many solutions.
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