Guest Blog: Are we getting value from our healthcare technology?

A recent article by Tim Wilson caught my attention and I asked Tim if I could share it wiht my readers on the eHealthMusings blog.  He graciously agreed.

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WRITTEN BY TIM WILSON ON JULY 18, 2018 FOR CANADIANHEALTHCARENETWORK.CA

The Council of Academic Hospitals of Ontario (CAHO) recently launched a new tool to help hospitals pull innovation into Ontario’s healthcare system. The tool is actually a quick reference guide titled “The Art of the Possible,” which exposes 16 myths with regard to public sector procurement in Ontario. The idea is that awareness of these myths will then help bring innovation into the system faster, while also improving patient care and health system efficiency.

It’s a reasonable idea, but it’s also debatable to what extent a 19-page reference guide can function as a strategic tool for improved procurement practices. Instead, it’s more of a handy factsheet. The guide itself, which was developed by a small panel of experts, claims to be of use for hospital executives and for individuals with intermediate to advanced knowledge of procurement. However, I can see how it would also be helpful for vendors who are either new to the market or considering entering into it.

The rationale for the reference guide was a 2016 survey across CAHO’s membership of Ontario’s 23 academic research hospitals, in which 76% of respondents identified “policies, directives and procurement rules as major hurdles to innovation adoption within their organizations.”

That isn’t surprising. What is surprising—to me at least—is that in setting out to expose the myths, CAHO is in effect saying that the barriers to innovation have more to do with a series of misunderstandings, as opposed to real structural problems.

The first myth tackled in the guide, and of course a real bugaboo in the discussion of value and innovation, is the notion that organizations must pick the lowest cost option in order to be consistent with the “value for money” principle in Ontario’s Broader Public Sector Procurement Directive.

The guide points out that value for money is to be assessed alongside accountability, transparency, quality service delivery and process standardization. And value for money itself can include other factors, such as the qualifications and experiences of the supplier.

The second myth is that organizations are stuck with traditional procurement models. In fact, the directive permits a variety of approaches as long as the approach is “fair, open and transparent and in compliance to the organization’s procurement-related trade obligations.” What that means is that negotiated requests for proposals (RFPs)—including with outcomes-based specifications—as well as competitive dialogue, innovation partnership, reverse auctions, and best and final offer, are all allowed.

Another myth is that the directive is inflexible; not true—as long as the procurement process is transparent, there are ways to build in flexibility. And organizations needn’t always go to market, given that non-competitive procurement processes are allowed in specific circumstances. The guide also asserts that the directive isn’t overtly bureaucratic nor is it only a “guideline”—compliance is required by law.

There are plenty of myths around vendor engagement, too. For example, you’re allowed to talk to vendors about unsolicited proposals outside of the procurement process, and RFPs can include opportunities for alternative proposals. Importantly, the guide clarifies that requests for information (RFIs) and requests for expressions of interest (RFEIs) can’t be used to prequalify or shortlist vendors. That said, there is some wriggle room with regard to conflict of interest, which is worth knowing given how small the community is in Canada.

In the sometimes rarefied world of hospital procurement, the guide confirms that advance contract award notice (ACAN) is permitted when no other vendors can provide the good or service, or meet related conditions. And you can still negotiate with vendors if desired, so long as that intent is covered in the RFP. Before the procurement process is initiated there is also plenty of legitimate opportunity for market engagement.

With regard to intellectual property, all IP issues needn’t be resolved to start a pilot, though they should always be taken into consideration. As well, an open process may not be required for a pilot. It could kick in if you then move to actual procurement, but co-development may not always require you to go to market. To help with this, organizations can consider engaging a fairness adviser.

That summation of the 16 myths is a lot to digest, and the guide does an admirable job of setting the record straight. It’s a bit of an overstatement, however, to say that it offers any deep strategic advice. That said, as panel member and procurement expert Sarah Friesen has noted, the guide “will increase confidence in exploring innovation procurement opportunities,” which in itself is a worthwhile goal. To some extent, the guide helps flesh out CAHO’s role as an innovation broker with the office of the chief health innovation Strategist.

Where I see the “The Art of the Possible” having an important—and perhaps unforeseen—role is in the vendor community. Brian Mackie, co-chair of CAHO’s Innovation Broker Task Force and vice-president of finance and chief financial officer at Baycrest Health Sciences, has said that “this work is helping us pull new technologies into our hospitals faster.” If that’s true, then healthcare tech innovators will be thrilled with this shift in focus.

But they may be wary, as well. There’s much in the document that suggests Canada—or in this specific example, Ontario—can move beyond a pre-commercial test-market, with wave after wave of small-scale pilots, and little transformation when it comes to using procurement as a tool of innovation. Still, we remain in a zero-sum environment, in which stakeholders compete for limited budgets, and in which administrators are pressured to satisfy numerous disparate interests.

In these environments, no matter what method or scorecard system you use, there is often a temptation for the final decision-making to default to arbitrary, executive-level preferences for purchases that keep as many people happy while solving as many urgent problems as possible—often in limited timeframes. In these scenarios, the emphasis is on keeping the ship afloat as opposed to embarking on longer voyages that embrace at times nebulous concepts of “innovation” and “value.”

Here is where it might be helpful to have a larger strategic discussion with regard to how to make decision-making objective and autonomous, and what we really mean by “transparency.” We don’t really have full public transparency and accountability on how individual organizations allocate budgets, or to what extent final procurement decisions off of RFPs are autonomous from administrative interference. A strategic approach to dealing with the political reality of budget-conscious decision-making, the real size of opportunistic shadow spending, and the positive role that the vendor community can play, could help bring about the cultural shift needed to get the best technology into our hospitals.

 

Tim Wilson is principal of T Wilson Associates. Follow him on Twitter: @TimothyEWilson

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In Support of Hacking for Health

“If you never change your mind, why have one?” Edward de Bono.

Are hackathons useful in the health sector? In an article I wrote late last year, I admitted that I was still “on the fence.” Never one to be comfortable sitting on the fence, I have continued to explore this question and have slowly reached the conclusion that hackathons indeed have a role to play in driving the development of new health IT solutions and perhaps, more importantly, breaking down barriers that impede innovation.

Check out the rest of the article on Technology for Doctors.

Mike

 

Procurement Meets Moore’s Law

The following is an article that recently appeared in Healthcare Information Management & Communications Canada magazine:

My father, the consummate bargain hunter, has never heard of Moore’s Law.  Yet, on a regular basis, he takes advantage of the falling prices that are one its inevitable consequences.  My father has learned that he need only wait a couple of years after a new technology is announced for the price of products based on that technology to drop to the level he is willing to pay.   Paradoxically, the same rapid changes in technology that benefits consumers like my father may, in the context of long government procurement cycle, stifle innovation and lead to failed health IT projects.

In a 1965 paper, Intel co-founder Gordon Moore noted that “the complexity for minimum component costs has increased at a rate of roughly a factor of two per year” and predicted that this “rate can be expected to continue”.  This prediction became known several years later as Moore’s Law and has been the source constant innovation in the IT sector for more than half a century.

The impact of long procurement cycles on IT related procurement has been evident in the defence and aerospace industries from quite some time.  A 2006 book on C4ISR (Command, Control, Communications, Computers, Intelligence, Surveillance and Reconnaissance) for future naval strike groups prepared by the U.S. Naval Studies Board concludes:

“The current procurement process of the Department of Defense concentrates on buying ships, airplanes, tanks, and so on. Most of these items have lives that are measured in decades, with few major upgrades over their lifetime. Information technology is changing on the time line articulated in Moore’s law and does not fit into such a process.”

Closer to home, an article in Vanguard, a Canadian defence and security magazine notes:

“Today, the emphasis in federal government procurement is on inputs, with detailed specifications of what, in IT, are constantly moving targets.”

This same article quotes Kamel Shaath, chief technology officer of Kanata-based KOM Networks.  Mr. Shaath contends that “procurement even is inhibiting innovation at times because they [government agencies] are not able to take advantage of new technology.”  Mr. Shaath recommends:

“We need to foster innovation and to have procurement processes that allow the government agencies to embrace and adopt new technologies on a much more rapid pace.”

At the 2012 eHealth conference that took place in Vancouver earlier this year, the opening key note speaker, Dr. John Halamka, was openly critical of the processes used to procure health IT systems and claimed that these practices stifle innovation.    In a blog post written soon after the eHealth conference, Dr. Halamka asserts that “Traditional procurement approaches are likely to acquire technology at the end of its lifecycle.”

While procurement reform is certainly a hot topic, it will, by its very nature, take time to happen.  In the meantime, we might want to consider the advice of Chris Gunderson, a Research Associate Professor of Information Science at the U.S. Naval Post Graduate School and a retired U.S. Navy Captain.  Driven by what he call his “frustration at us Good Guys’ inability to get out of our own way when it comes to acquiring and applying to technology”,  Professor Gunderson is devoting the latter part of his career to “co-opt the government bureaucracy to consume my lessons learned about successful distributive, collaborative e-Biz ‘best practices’ in-spite of itself.”

In an October 2009 interview with Ubiquity magazine (an Association of Computing Machinery publication) Chris Gunderson makes a similar case regarding the challenges of IT procurement in the face of rapid technological advances as others quoted in this article:

“The downside of all these restrictions is that the time for the government to procure and deliver a major system is easily a decade or more. With the environment of use changing at the rate of Moore’s Law, the delivered systems are almost always obsolete or obsolescent.”

While acknowledging these challenges, he offers hope that they can be overcome:

“I’ve learned that the best way to achieve powerfully disruptive change is by subtly co-opting the existing processes. By “co-opt” I don’t mean anything subversive or underhanded. I simply mean we should introduce more convenient and efficient methods within the constraints of the existing bureaucratic requirements. The improvements will be adopted because they are perceived as both comfortable and useful.”

Mike

Ontario Diabetes Registry – Doomed from the start?

Over the week several readers of my blog, eHealth Musings, have asked me to comment on eHealth Ontario’s recent decision to terminate its contract with CGI to build an electronic Diabetes Registry.  Check out my article on this topic at Technology for Doctors.

Mike