GUEST POST from Arlen Meyers

The IHI Triple Aim is to lower per capita costs, improve the quality of outcomes and improve the patient experience.Add the doctor experience and you have the quadruple ain. Some patient engagement and experience experts say there are 5 steps to making it happen:

1. Establish vision

2.Create a culture of engagement

3. Employ the right technology

4.Empower patients

5. Be ready to evolve.

Others have outlined how to get it done.

It’s been demonstrated over and over again that happy employees make happy customers. Likewise, burned out, unhappy doctors make unhappy patients. The key to the patient experience is the doctor experience, yet employers and organized medicine have dropped the ball and don’t seem to see the link. Physician burnout is now a public health crisis with more than half of doctors feeling the sting. What/s more, no one has a lasting cure.

In 1981, the psychologist Christina Maslach, working with several colleagues, set out to create a test to measure occupational burnout. Eventually termed the Maslach Inventory, the scale assessed the risk of burnout by testing subjects along three basic dimensions: emotional exhaustion, depersonalization and personal accomplishment. The first set of questions, nine in total, measured the feeling of being chronically overextended or emotionally fatigued in the workplace. The second, with five items, tried to capture the feeling of becoming detached or disconnected from the recipient of your services: toddlers in the case of kindergarten teachers, or patients in the case of doctors (“I haven’t even touched a patient,” as the resident put it). The final dimension that Maslach identified, through eight questions, was a loss of personal accomplishment, a feeling that nothing was being achieved.

The AMA’s STEPS Forward collection offers free online modules that help physicians and system leaders learn their risk factors for burnout and adopt medical practice solutions to reignite professional fulfillment and resilience, including modules that focus on how to change key workflows and processes, such as pre-visit planning and synchronized prescription renewal.

In 2016, Carilion Clinic conducted a survey encompassing physician burnout and employee engagement. The survey was distributed to all physicians, residents and fellows, advanced care practitioners and medical students in the system.

The results were sobering. Fifty-nine percent of Carilion physicians were experiencing high burnout. Half of medical students, physician assistants and nurse practitioners also reported burnout, with burnout being worst among residents. The survey renewed Carilion’s focus on efforts to rectify widespread burnout. Leaders came up with these seven innovative ideas and initiatives, as outlined in an AMA STEPS Forward™ module.

Burnout takes not just a human toll, but a financial one as well.

If nothing were done to address burnout, two Stanford researchers estimated, almost 60 physicians would leave Stanford within two years. The cost of recruitment for each physician—depending on the specialty and rank of faculty—would range from more than $250,000 to almost $1 million. And, for those 58 physicians, Stanford’s economic loss over two years would range from a minimum of $15.5 million to a maximum of $55.5 million.

EMRs have become the burnout scapegoat, but there are 5 main sources of burnout ,which mostly have to do with the loss of control and authority and not having the right tools and support to do your job.

1. The practice of clinical medicine.

2. Your specific job.

3. Having a life.

4. The conditioning of our medical education

5. The leadership skills of your immediate supervisors.

To address the problem we need to PISS on it:

1. Prevention. Burnout prevention interventions are effective but tend to fatigue. They need to reinforced periodically.

2. Innovation: We need better ways to intervene and prevent relapse. For example, peer-to-peer network support systems provide peer supporters to those who have experienced an adverse medical event and need someone to talk to them.

3. Surveillance: Few health service organizations or academic medical centers monitor burn out or employee disengagement and usually depend on self reporting or flushing out the bad apples. It does not work. Doctors, like military personnel, have a warrior mentality that places stigma on those who won’t man up.

4. Stewardship: We need better ways to shield harried doctors from adminstrivia and anything that prevents them from practicing to the top of their license.

Members of a recent AMA summit issued this call to action:

They committed to:

1. Regularly measure the well-being of our physician workforce at our institutions using one of several standardized, benchmarked instruments.
2. Where possible, include measures of physician well-being in our institutional performance dashboards along with financial and other performance metrics.
3. Evaluate and track the institutional costs of physician turnover, early retirement, and reductions in clinical effort.
4. Emphasize the importance of leadership skill development for physicians and managers leading physicians throughout our organization.
5. Understand and address more fully the clerical burden and inappropriate allocation of work to physicians that is contributing to professional burnout.
6. Support collaborative, team-based models of care where physician expertise is maximally utilized for patient benefit, with tasks that do not require the unique training of a physician delegated to other skilled team members.
7. Encourage government/regulators to address the increasing regulatory burden that is driving inefficiency, redundancy, and waste in health care and to proactively monitor and address new unnecessary and/or redundant regulations.
8. Encourage and support the AMA and other national organizations to work with regulators and technology vendors to align technology and policy with advanced models of team-based care and to reduce the burden of the EHR on all users.
9. Encourage and support the AMA and other national organizations in developing further initiatives to make progress in this area by compiling and sharing best practices from institutions that have successfully begun to address burnout, profiling case studies of effective well-being programs, efficient and satisfying changes in task distribution, and outlining a set of principles for achieving the well-being of health professionals.
10. Continue to educate our fellow CEOs as well as other stakeholders in the health care ecosystem about the importance of reducing burnout and improving the well-being of physicians as well as other health care professionals.
11. Support and use organizational research at our centers to determine the most effective policies and interventions to improve professional well-being among our physicians and other health care professionals.

Happy, productive doctors make happy patients and that drives revenue. Plus, the direct and indirect costs of burnout and turnover justify the investments and boosts the ROI.

Organizational behavior experts tell us that the single biggest cause of job stress is lack of control. Rules, red tape, interference, and IT mandates that don’t help doctors take care of patients don’t help and demoralize doctors. Creating a better attitude is about giving employees control, not wresting it from them.

These workplace factors contribute to burnout in family physicians.

Physician burnout can be reduced by interventions at the individual and organizational level.

These burnout risk factors should be measured and addressed at an organizational level to help restore joy to the day’s work.

Workload: The demands of your job exceed the resources available to accomplish it.

Control: You have very little say over how you do what you do—and no one is interested in your feedback.

Rewards: Rewards are less about salary and benefits and more about recognition for a job well done. If the best you can say about your workday is that “there were no screamers today” or “nothing bad happened,” then you and your workplace are in trouble, Maslach noted.

Community: “Unresolved conflicts that fester over time into a socially toxic environment” may lead to anti-social behaviors, such as bullying and rudeness, Maslach said.

Fairness: A perceived lack of equity in the workplace—one in which success “depends on who you know” rather than experience and expertise—can result in anger and hostility.

Values Conflicts: A disconnect between the values that give meaning to your life and your day-to-day work realities can chip away at your sense of self, with long-range consequences.

What is missing is intervention and change at the systemic level or regulatory level.. If anything, top down rules, regulations and constant policy changes from Washington is causing change fatigue and making matters worse.

Here are some organizational strategies to reduce burnout:

1. Acknowledge the problem and measure it.

2. Utilize the power of leadership.

3. Focus on providing job resources

4. Minimize job demands and conflict

5. Promote work-life integration

6. Promote individual resilience

Here are some tips on building personal resilience:

1. To build and work your plan for greater resilience, strengthen your CORE.
2. Adjust your mindset
3. Practice resilience on the small stuff

Be sure you are measuring the right thing with instruments that are valid.

We need to rename the Triple Aim the Quadruple Aim and many professional associations are supporting the movement to restore the joy in medicine.

Note to administrators:Results indicated that organizational commitment had a more persistent influence on performance at the business unit level than vice versa. Consistent with prior research, this suggests that job attitudes may come first, and that practitioners might be well advised to aim to improve job attitudes in order to boost performance.

Employed physician engagement is not as high as their employers think it is, and conceivably, could drop even more in the future.

Health professional burnout will have to be addressed at 3 levels: individual, organizational and systemic. The last one is the most problematic given the conflicting interests and resistance to change. Here is an example. Although most physicians view the delivery of high-quality care as a professional imperative, performance-measurement activities face increasing resistance from physicians and some policymakers who believe that current measures are not meaningful. In a recent survey, 63% of physicians said that current measures do not capture the quality of the care that physicians provide. Yet U.S. physician practices are spending $15.4 billion each year — about $40,000 per physician — to report on performance.

Burnout and depression rates among U.S. physicians failed to improve in 2019, despite growing efforts by healthcare organizations, hospitals, and academic centers to address the issue through wellness programs and other interventions

Did you get the memo?

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GUEST POST from Arlen Meyers

I think “health administration” is an anachronism, since we have a sick care system masquerading as a health care system and the last thing we need is more administrators, rather than leaderpreneurs.

Consequently, those offering programs to students interested in being health systems administrators offer courses and measure competencies designed to fight a phony war.

Instead, they should be requiring graduates to demonstrate the following knowledge, skills, abilities and competencies:

1. How to hire physician intrapreneurs and what to do with them once you have
2. Understand AI and machine learning and what to do with the results of algorithms.

3.How to overcome the barriers to US and international biomedical innovation and entrepreneurship

4.How to lead innovators

5.Success factors for successful organizational innovation

6.How to address the social determinants of adverse health outcomes

7.How to recruit, train, promote and retain a diverse talent pipeline

8.How to win the the 4th industrial revolution

9.How to improve the health professional, health care team, patient family and friends care team experience

10.How to change doctor and patient behavior and transform sick care to health care.

11. How to break down innovation silos in regional clusters

12. How to eliminate sick care worker burnout

13. How to reconcile the ethics of business with the ethics of medicine

14. How to switch from fee for service to value based care

15. How to give white coats the pink slip

Pillay, et al, have defined the healthcare innovation competencies as:

Opportunity recognition pertains to one’s ability to scan and search for new information, connect the dots between incidents that appear to be unrelated with limited cues, and recognize patterns or ideas that suggest potential opportunities in the myriad cues or signals that they receive (Baron, 2006).

Conveying a compelling vision/seeing the future reflects an individual’s proclivity for effective communication where he or she can translate his or her vision into condensed, clear, and intriguing messages to important stakeholders (Chen, Yao, & Kotha 2009).

Ability to maintain focus yet adapt speaks to the entrepreneurial experience. This ccan include considerable ambiguity and uncertainty, significant obstacles, ongoing emergence of new opportunities, and continuous change in circumstances (Morris et al., 2012). The entrepreneur must continuously adapt, change, modify, and switch while maintaining a self-regulated focus in the midst of volatile conditions (Haynie & Shepherd, 2009)

Resilience captures the cognitive tendency of an individual to cope with stressful, adverse, and devastating situations, to be able to recover from failures, and to constructively sustain his or her efforts to pursue goals. In reality, successful entrepreneurs are not easily beaten by distress or rejections. Instead, they are able to remain or resume a calm state of mind, to tactically frame and analyze problems, dig into the root cause of failures, and to search for ways to get back on track again (Sinclair & Wallston, 2004).

Interdisciplinary teamwork and collaboration refers to the ability of individuals to form partnerships with a team of professionally diverse individuals in a participatory, collaborative, and coordinated approach to share decisionmaking around issues as the means to achieving improved health outcomes (Orchard & Curran, 2003).

Assessing the feasibility of an opportunity emphasizes the need for innovators to make evaluations or judgments on whether emerging information or changes would lead to viable opportunities with profit potential (McMullen & Shepherd, 2006).

Self-Efficacy/Confidence relates to an entrepreneur’s self-confidence and selfassurance about his or her ability to take on challenges, to perform certain set of tasks as needed or expected, and to control processes, contingencies, or consequences in the entrepreneurial pursuit (Bandura, 1997; Baron & Markman, 2005; Tierney & Farmer, 2002).

Building and using networks concerns one’s ability to establish, maintain, and structure his or her contact network(s) in ways that foster relationships, enhance access to opportunities and/or resources, and potentially lead to realization of his or her objectives (Aldrich, 1999).

Tenacity/Perseverance refers to the extent to which entrepreneurs are committed to seeing their vision through, to endure the long journey to carry out venture creation, to work fervently despite challenges or adversity, to maintain interests, and persist with efforts in achieving goals (Duckworth & Quinn 2009; Hmieleski & Corbett, 2006).

Understanding of healthcare systems entails having a firm grasp of the various components of the health system and an understanding of the major issues faced by the stakeholders.

Resource leveraging/Bootstrapping describes the need to overcome resource constraints by leveraging resources from others. It also reflects a tendency for innovators to demonstrate an inclination towards effectual rather than causal reasoning in bringing together unique resource combinations (Greene &Brown, 1997; Honig, 2001; Politis, Winborg, & Dahlstrand, 2011).

Creative problem solving/Imaginativeness is characterized by Schumpeter (1942), who posited that creative destruction plays a key role in the innovation process. Innovators who start something are engaged in a process of creative imagination in which opportunities are exploited by continuously combining resources in new ways (Kirzner, 1973; Chiles, Bluedorn, & Gupta, 2007).

Design thinking is a human-centered, prototype-driven process for innovation that can be applied to product, service, and business design. It is the process of questioning, observing, and experimenting, so that you can become better equipped to capture valuable information and develop new business ideas. It requires experimentation in order to understand how things work, to test new business ideas or different approaches, and to look for valuable insights that may emerge in the process (Brown, 2008).

Guerrilla skills is a label adapted from a warfare context, describing approaches that center on clever ways to take advantage of one’s surroundings, do more with less, to rely upon unconventional tactics, and to utilize resources not recognized by others in accomplishing tasks within entrepreneurial firms (Schindehutte, Morris & Pitt, 2008).

Risk management/mitigation involves the systematic monitoring, assessing, hedging, transferring, and/or exploiting multifaceted risks encountered as an innovation initiative unfolds. Risk-aversive attitudes discourage individuals from innovative activities (Cramera et al., 2002), while successful entrepreneurs are willing to first recognize and bear the uncertainty or risk needed to take entrepreneurial actions, and are able to manage risk rather than simply trying to avoid risk (McMullen & Shepherd, 2006).

Cross disciplinary knowledge refers to an understanding of the connections, interrelations, and interactions between different fields of knowledge (Mosseri, 2006).

Change management is the ability to understand and manage driving forces, visions, and processes that fuel large-scale transformation (Kottler, 2011).

Information management is the collection and management of information from one or more sources and the distribution of that information to one or more audiences.

Behavioral economics refers to an understanding of psychological, social, cognitive, and emotional factors on the economic decisions of individuals and institutions, and the consequences for market prices, returns, and resource allocation (Lin, 2012). It is the understanding that drives decision making.

Whether you get an MD/MBA/MHA/JD/MPH or some other concoction of credentials, it is likely that you will have blind spots and that they won’t be filled in your formal training. Try not to let school get in the way of your education.

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GUEST POST from Arlen Meyers

A bubble is an economic cycle characterized by the rapid escalation of asset prices followed by a contraction. It is created by a surge in asset prices unwarranted by the fundamentals of the asset and driven by exuberant market behavior. When no more investors are willing to buy at the elevated price, a massive sell-off occurs, causing the bubble to deflate.

The pattern of a bubble is pretty consistent, despite variations in how the cycle is interpreted.

1. Displacement: This stage takes place when investors start to notice a new paradigm, like a new product or technology, or historically low interest rates — basically anything that gets their attention.
2. Boom: Prices start to rise at first, then get momentum as more investors enter the market. This sets up the stage for the boom. There is an overall sense of failing to jump in, causing even more people to start buying assets.
3. Euphoria: When euphoria hits and asset prices skyrocket, caution is thrown out the window.
4. Profit taking: Figuring out when the bubble will burst isn’t easy; once a bubble has burst, it will not inflate again. But anyone who looks at the warning signs will make money by selling off positions.
5. Panic: Asset prices change course and drop as quickly as they rose. Investors and others want to liquidate them at any price. Asset prices decline as supply outshines demand.

A somewhat similar model is the Gartner Hype Cycle.

Some think that there is a digital health bubble, an innovation bubble, a higher ed bubble , a graduate school bubble, a law school bubble and maybe even a medical school bubble.

One report suggests that leading digital health companies have not yet demonstrated substantial impact on disease burden or cost in the US health care system. The findings indicate the importance of fostering an environment, with regard to policy and the consumer market, that encourages the development of evidence-based, high-impact products.

Sick care innovation centers aren’t much better.

I believe whether you believe there is a bubble or not depends on the lens you use to see progress and how you define  and measure the outcome and impact of new things or old things done in a new way:

1. There might be technology bubbles, but technologies are not necessarily innovations i.e new things or old things done in a new way that create significant multiples of user defined value i.e quality/cost. Here is what you should know about innovation and how to measure it.
2. Sick care innovation takes a long time and constantly evolves, building on scientific and technological inventions and discoveries requiring a supportive culture, leaderpreneurs and ecosystems.
3. There are significant barriers to sick care innovation dissemination and implementation, so you need to take the long view
4. Occaisionally, significant innovations, like anesthesia, antibiotics or clean water, significantly shifts the curve with a rare demonstration of a paroxysm of progress
5. There are many stakeholders in sick care and each one values a product or service differently and asks for a different value proposition. For example, doctors value quality, patients value experience and convenience. What is a bubble to one is a boon to another
6. Sick care is a highly regulated industry so the path of progress depends as much on socioeconomic and political winds as it does discovery or inventions
7. Translating inventions to innovations is the work of entrepreneurs. The sick care entrepreneurial workforce and entrepreneurial cultures are in their infancy. The entrepreneurial mindset is foreign to most sick care professionals.
8. The educational and workforce models and the resulting talent pipelines producing knowledge technicians are archaic and outdated
9. The business model of Sickcare USA is not designed to create or value innovation or teach participants how to create it
10. There is no Moore’s Law in sick care so innovations many times translate into increased costs, not lower ones

There might be technological bubbles, like the dot come bust or digital health froth, but I don’t think there are sick care innovation bubbles. If anything, we are just beginning to learn how to translate inventions to innovations and data to value. Given the pace of progress, many of us won’t be around to see the results, let alone hear the pop.

Like the old Chinese proverb goes, “If you want to know what water is, don’t ask the fish”

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GUEST POST from Arlen Meyers

Sickcare professional entrepreneurs come in several flavors: private practitioners, technopreneurs, social entrepreneurs, edupreneurs, academic entrepreneurs, service providers and physician investors.

Some are intrapreneurs i.e. employed physicians trying or expected to add value to their employers by acting like entrepreneurs. In other words, they are trying to create employer defined value through the deployment of innovation by deploying a product, service or model that is designed to improve quality, access and the doctor and patient experience while decreasing costs.

What’s more, there are some basic biomedical and clinical innovation roadmaps- drugs, devices, digital health and care delivery, be it internal or something others can use outside of your organization. Each requires different knowledge, skills, abilities and competencies.

A lot has been written about how to innovate in your organization and overcome the barriers. The stops along the intrapreneur innovation roadmap typically involve:

1. Picking the right problem to solve
2. Creating the right product that solves the problem
3. Finding the right champion with the passion, perseverance and political savvy to execute
4. Helping the champion build a team that includes the right partners and sponsors
5. Overcoming the processes within the organzation that are barriers or working around them
6. Making sure that everyone is focused on the same purpose or desired results that are aligned with organizational priorities
7. Not punishing failure
8. Enabling pilots to demonstrate proof of concept that do not leave innovators in pilot purgatory
9. Pricing the solution appropriately and using the right revenue model
10. Punting on the idea when the evidence indicates the dog won’t eat the food

Here’s why you should hire physician intrapreneurs and what to do with them once you have. It doesn’t always go by the book,

Getting your intrapreneurial idea over the goal line is hard. Be sure mind your P’s (and Q’s) when you try.

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GUEST POST from Arlen Meyers

Every entrepreneur who has succeeded or failed (is there a difference?) has advice about how to get the right people on the bus. What questions should you ask at the interview? What character traits should you seek and how do you do that? How much is science and how much is just going with your gut and whether you click?

What Google found was that interview scores had no correlation with performance, of those who got hired.

Likewise, advisors or potential employees want to find the right fit as well. The rules are somewhat different when it comes to the board of directors, the management team, employees, consultants and advisors.

Maybe flipping a coin or a job lottery would save a bunch of time and money and get the same results.

I’ve been on both sides of the table so allow me share my two cents on how to staff your startup:

1. Hope for the best and expect to fire fast. Give yourself lots of wiggle room.

2. Don’t hire hood ornaments (doctors with fancy credentials that you parade on your website and pitch deck) unless you simply need one for credibility and really don’t expect them to do much more.

3. Clarify expectations, timelines and benchmarks

4. Rent advisors, don’t buy them

5. Barter, don’t rent, if possible

6. Expect most people to put a hand up, not show up

7. Define your next critical success factor (like raising 2M dollars in seed money) and find people who can help get it done. Once it’s done, stop and empty the bus, and reload. For example, suppose your company has achievements to date that include FDA 510(k) submission, provisional and non-provisional patent filing (there is no such thing as a non-provisional patent granted by the USPTO), and patent attorney freedom-to-operate letter (here’s what that is). You have raised $200,000 from angel investors and are currently raising $1.5M in the current seed round with a valuation of $10M. Who do you want to help, how and how much will you compensate them and for how long?

8. Don’t give away the store early in the game. If you are successful, you’ll have to give it away to get the money anyway so keep your powder dry

9. Hire people who are card carrying members of the Get Shit Done Club  

10. Evolve as fast as you can from a knowledge technician to manager, to leader, to entrepreneur to leaderpreneur i.e. work on the company, not in it.

11. Be careful about hiring interns since there are practical and labor law issues that can make your life more complicated than it already is or is going to be. Internships are supposed to be about helping the intern. You want people who primary purpose is to help your company as much and as soon as possible

12. Don’t overhire for quality or quantity. Do you really need to hire that expensive CFO when what you really need is someone to keep the books and do payroll at this stage of the game? What about business development, sales and marketing?

13. Figure out whether you are hiring someone, or joining someone, to help with strategy or tactics. At the beginning, it is usually a cacophany of both. As the company validates its model, though, there is the risk of the distraction of traction. For a surgical benefits management company, for example, you need to focus and define your SCOPE.

14. The single most important question you can ask yourself is, “Do I like and trust these people?” The second is, “Can I deliver what they want, or am I just doing this to stroke my ego and make some bucks?”

15. If you had one more day to live, would you spend it in a co-working space wearing a hoodie? How about training and hiring felons?

16. Promote intergenerational collaboration

Here are some tips on hiring sales people and avoiding the mistakes.

This on-demand talent model, dubbed SPEED by the author (Success, Plan, Execute, Evaluate, Decide), is good for the company, and good for all specialized, dedicated, and high performing people in the workforce today. Your company gets the flexibility to adapt quickly to the needs of a rapidly changing marketplace, and workers get to broaden their experience in the work they love.

One empirical analysis shows that companies that are equipped with both business and technical skills are disproportionately more likely to introduce new-to-the market innovations than firms that have only one of these skills. However, not all firms that are equipped with both types of skills are able to profit from them. Firms profit disproportionately from a mix of business and technical skills when the founder has technical knowledge and employs additional business experts. By contrast, we find no evidence of complimentary either when business and technical skills are balanced within a founding team, or when a founder with business skills hires employees with technical skills.

Entrepreneurial startup success is about entrepreneurial startup TEAMwork i.e.finding the people:

1. Who have Talent
2. Who can Execute
3. Who can Articulate a vision, mission, values and strategy
4. Who know how to raise, manage, protect and make large sums of Money

That means you will have to find people who play some skill positions like problem seeker, problem solver, money finder, score keeper, product developer, business builder, dot connector, risk manager and story teller.

The startup lineup should also have people in it with these skills and abilities.

How do you compensate these people without breaking the startup bank? Here are some ideas.

Hiring the right people makes the difference between fun and misery. Plan to make lots of mistakes and fire fast. Pivoting often means taking casualties.

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GUEST POST from Arlen Meyers

Doctors and their patients are joining forces in a pitched battle. There are six technologies that are colliding in sick care. They represent the front lines of the 4th Industrial Revolution. Which side wins will have significant impact on the future of medicine and society.

The 4th Industrial Revolution is a mental model created by the leaders of the Joint Economic Forum and describes how physical, digital and biologic technologies have collided and the resulting challenges and opportunities that presents. Strategies to win the revolution are designed to create guardrails around the potential collateral damage. But minimizing that damage will take state of the art weapons:

1. Rules and regulations for 4th industrial revolution technologies that balance the public health with innovation
2. Educational systems that create a diverse talent pipeline with the knowledge, skills and abilities to win the war
3. Rethinking STEM education
4. Stress the arts and soft skills education as part of public education with the necessary funding to support it
5. Create cost effectiveness screens for digital health products and services
6. Enforce tougher cybersecurity protections
7. Reform digital health reimbursement and payment rules
8.  Turn sick care into health care by paying for health
9.  Lead the revolution innovators, don’t manage innovation
10.  Rethink federally funding university and federal research lab technology transfer

We will need a new operating system for the 4th industrial revolution.

The American Medical Informatics Association is urging the Trump administration to leverage an existing industry strategy on artificial intelligence research and development, rather than beginning from scratch.

DARPA is a government agency responsible for developing and deploying weapons for warfighters of the future. We need CARPA- The Cyberhealth Advanced Research Projects Agency- to man the war room and do the same for doctors and their patients and an “czar” to run it.

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GUEST POST from Arlen Meyers

Do you wonder why some innovations diffuse, while others don’t? These days, we like to use trendy buzz words like scaling, getting traction and going viral, but the meaning is the same. But, there are many terms and concepts that are being used that are confusing , so here are some basics to set you straight:

1. Who, when, why and how people adopt new ideas goes back to Everett Rogers and his book, Diffusion of Innovations
2. Implementation science is the systematic study of strategies and factors associated with the successful integration of evidence-based interventions and policies into practice (and de-implementation of wasteful and ineffective programs). Adoption is another term describing the same thing.
3. Dissemination research involves the study mechanisms and approaches to communicate and spread information targeted to potential users to accelerate adoption and implementation (going to scale). Another term for it is penetration.

4. The five stages of the adoption process are:

1. Knowledge (Awareness): In this stage the individual is first exposed to an innovation but lacks information about the innovation. During this stage of the process the individual has not been inspired to find more information about the innovation. Hint: How can social media drive curiosity?
2. Persuasion/ Intention: In this stage the individual is interested in the innovation and actively seeks information/detail about the innovation. Hint: How can smart website content on the Google search results page help educate this potential user?
3. Decision: In this stage the individual takes the concept of the change and weighs the advantages/disadvantages of using the innovation and decides whether to adopt or reject the innovation. Due to the individualistic nature of this stage Rogers notes that it is the most difficult stage to acquire empirical evidence (Rogers 1964, p. 83). Hint: How can you make the first digital experiences with the brand enjoyable and useful?
4. Implementation/Action: In this stage the individual employs the innovation to a varying degree depending on the situation. During this stage the individual determines the usefulness of the innovation and may search for further information about it. Hint: How can you build an online community to help new users get up to speed on using your product or service? Can you craft content such as a “Beginner’s Guide with FAQ’s”?
5. Confirmation/Validation: Although the name of this stage may be misleading, in this stage the individual finalizes his/her decision to continue using the innovation and may use the innovation to its fullest potential or abandon it altogether. Hint: How can you reassure a user in real-time they made the right decision?

Here are the five customer segments by rates of adoption:

Innovators (2.5%) – Innovators are the first individuals to adopt an innovation. Innovators are willing to take risks, youngest in age, have the highest social class, have great financial lucidity, very social and have closest contact to scientific sources and interaction with other innovators. Risk tolerance has them adopting technologies which may ultimately fail. Financial resources help absorb these failures. (Rogers 1962 5th ed, p. 282)

Early Adopters (13.5%) – This is the second fastest category of individuals who adopt an innovation. These individuals have the highest degree of opinion leadership among the other adopter categories. Early adopters are typically younger in age, have a higher social status, have more financial lucidity, advanced education, and are more socially forward than late adopters. More discrete in adoption choices than innovators. Realize judicious choice of adoption will help them maintain central communication position (Rogers 1962 5th ed, p. 283).

Early Majority (34%) – Individuals in this category adopt an innovation after a varying degree of time. This time of adoption is significantly longer than the innovators and early adopters. Early Majority tend to be slower in the adoption process, have above average social status, contact with early adopters, and seldom hold positions of opinion leadership in a system (Rogers 1962 5th ed, p. 283)

Late Majority (34%) – Individuals in this category will adopt an innovation after the average member of the society. These individuals approach an innovation with a high degree of skepticism and after the majority of society has adopted the innovation. Late Majority are typically skeptical about an innovation, have below average social status, very little financial lucidity, in contact with others in late majority and early majority, very little opinion leadership.

Laggards (16%) – Individuals in this category are the last to adopt an innovation. Unlike some of the previous categories, individuals in this category show little to no opinion leadership. These individuals typically have an aversion to change-agents and tend to be advanced in age. Laggards typically tend to be focused on “traditions”, likely to have lowest social status, lowest financial fluidity, be oldest of all other adopters, in contact with only family and close friends, very little to no opinion leadership.

5. Most of us buy emotionally and justify rationally.

6. Here are the ABCDEs of technology adoption and errors.

7. As a digital marketer, you have the unique first-time opportunity to touch a consumer across all five steps of this process.

8. Here’s where crossing the chasm meets the lean startup in digital health

9. Here are the 6 dysfunctions of engaged communities

10. Here are some reasons why doctors don’t care about customer service and why they won’t text you

Here are some things innovators can learn from failed innovation efforts in sick care.

A major challenge in sickcare is the amount of time it takes for an evidence based innovation to disseminate into clinical practice. AI aggregation of scientific information might help. New D/I techniques might help. Behavioral economic and social psychologic techniques might help.

The next time the dog won’t eat your food, think about why. The answer is somewhere above.

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GUEST POST from Arlen Meyers

Victor Fuchs and Mark Cullen published an article in JAMA questioning the impact of health systems change on doctors and how the medical educational establishment should respond with curriculum reform that includes, among other things, health economics and population health.

They further provide a short history of healthcare policy and structure and how it has evolved from an unregulated industry to one that has become increasingly corporatized. They note the rise in employed physicians and that :

Physicians might become less professional, but their professional role could increase as their entrepreneurial role decreases

It seems to me there is confusion about physician entrepreneurship,its definition and whether it represents a threat to professionalism. I’m not alone. Is a physician entrepreneur someone who starts and runs a business, or is it something more?

1. Entrepreneurship is the pursuit of opportunity with scarce, uncontrolled resources. The goal of all entrepreneurs, including physician entrepreneurs, is to create user defined value through the deployment of innovation using a VAST business model

2. Innovation has both a qualitative and quantitative component. It refers to doing something new or something old in a new way that creates user defined value that is a significant multiple of the competitive offering. Sick care sorely needs innovation that is not incremental or sustaining, but rather significantly adds at least 10x the present value to have an impact.

3. Physician entrepreneurship is not the same things as private practice nor is it fundamentally about practice management. The increasing rate of employed physicians should not be interpreted, as Prof. Fuchs implies, as decreasing entrepreneurial role of doctors and its consequent impact on medical professionalism. To the contrary, when done properly, it enhances medical professionalism.

4. There are many different goals and roles for physician entrepreneurs as small to medium sized business owners in private practice, technopreneurs, social entrepreneurs, intrapreneurs i.e.employed physicians acting like entrepreneurs, freelancers and consultants, and physician investors. Social entrepreneurship has a long history of physician involvement and business school courses in social entrepreneurship and impact investing are expanding.Here is a recent example of how one doctor is making a difference.

Roles can vary as well. Some physician entrepreneurs are problem seekers, others problem solvers. There are also story tellers, money finders, score keepers, social connectors, risk managers and business developers.

5. Employed physicians, whether academic or non-academic, have the potential to be no less entrepreneurial than their colleagues who are in independent practices.

6. While medical educational reform is necessary, expecting medical students to master health economics and population health is an unrealistic expectation. Medical schools need to be part of entrepreneurial universities with the goal of instilling an entrepreneurial mindset in all graduates, including health professionals. To that end, medical schools and their graduates schools should rethink how they teach and practice technology transfer and commercialization and how they give faculty innovators the tools, incentive and recognition for the scholarship of innovation they deserve.

7. Physician entrepreneurship enhances medical professionalism, it does not degrade it, as long its practitioners understand and resolve the conflicts between the ethics of medicine and the ethics of business. Violating the patient or public trust by self dealing or undisclosed conflicts of interest degrades any profession that has a fiduciary relationship with its customers or clients.

8. Physician entrepreneurs create value for patients in many ways other than seeing them face to face for an entire professional career. The upcoming generation of medical students and residents and scientists and engineers in graduate school understand that better than their school’s faculty and administrators and they have engaged in bottom up efforts to fill the gaps in their education and experiences.

9. Every threat to the existing practice of medicine, whether, as noted, it be acute care to chronic care, face to face care to digical care, or corporate care evolving into more patient centered care, represents an opportunity for physician entrepreneurs to help patients by adding value.

10. Every industrialized country is facing the issue of how to provide their citizens with health services with scarce resources. Innovation and entrepreneurship , fostered by rules that catalyze them, will be the solution.

Physician entrepreneurs whether as technopreneurs, medical practice entrepreneurs, intrapreneurs or international social entrepreneurs are making a difference. This non-profit group is trying to eliminate the stigma of mental illness in Nigeria.

The “golden age” of medical practice is being replaced by the “golden age” of physician entrepreneurship since there has been, arguably, no better time to be a doctor who sees the business of medicine as creating value on par with the practice of medicine as another way to help patients.

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GUEST POST from Arlen Meyers

Raising money is hard, whether it be for a for profit or not for profit. You will need a plan and the right people to do it. For most entrepreneurs, it is a full time consideration.

If you plan to raise money, here are some mistakes to avoid:

1. Not having a capital raising plan
2. Not learning how to tell your story or finding someone who can
3. Focusing on features and not benefits
4. A product or service that is not ready for investor prime time
5. A product or service that is not ready for health system prime time
6. Wrong people on your team
7. You suffer from Founder’s Syndrome
8. You suffer from Craniorectal Inversion Syndrome
9. You make too many rookie mindset mistakes
10. You don’t have a VAST business model that is evidence based
11. You have not mastered the fundamentals of entrepreneurship
12. You haven’t navigated the bumps in the road
13. Not paying attention to new trends in financing ventures
14. You are Linkedout and have limited networks
15. Your website is all about you. I’ll bet you think this blog is about you, don’t you.

Here is why your startup will fail, and , more specifically, why your digital health startup will fail.

Raising money, like all business, is about developing relationships with the right people at the right time. Re-read How to Win Friends and Influence People.

Better yet, I know you won’t take my advice since that will take more time than watching a 3 minute You Tube video, so here is a summary. OK. Here’s the You Tube video too.

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GUEST POST from Arlen Meyers

Here were my entrepreneural goals for 2018 which, I suspect, won’t change much from year to year. The good news is I still make my bed every morning.

If you are are a physician entrepreneur, 2019 will be another year of opportunity. In order to create user defined value through the discovery, development and deployment of innovation, you will need to continue lifelong learning, find the resources, build robust internal and external networks, work with mentors and mentees, get peer to peer support and continue working on your personal and professional talent development plan.

Here are five trends that are sources of innovation.

Here are some articles from this year that might help you find your way:

1. How to be a physician entrepreneur despite your MBA I graduated Jefferson Medical College in 1972. I graduated with an MBA from the University of Colorado in 1984. Given my interests in biomedical and clinical innovation and entrepreneurship, it seemed like a good idea at the time. So much so, in fact, that I led the initiative on campus to create our own MD/MBA program. Over half of US medical schools now offer the dual degree programs.

2. The pros and cons of medical experience. Medical education is an apprenticeship and has been so for thousands of years. It is unlikely to change in the near future. Consequently, the model reveres the teacher and places obligations to the student, even by taking an oath.

3. How do I know whether my surgeon is doing unnecessary surgery? Unnecessary surgery is a big problem. Here is an article that describes the problem and its size.The fact is that any doctor has a fiduciary responsibility to do what’s right for the patient. However, as long as proceduralists (not just surgeons) get paid to do procedures (regardless of FFS or bundled payment), there will be an inherent conflict of interest. I don’t think it will ever be eliminated, but there are steps we can take to mitigate it.

4. How to create more physician pharma-technopreneurs Most physician entrepreneurs, particularly those still in clinical practice, are more interested in devices, digital health and care channel, process and model improvement or innovation. For the drug industry, that is a problem since there are many exciting opportunities.. Given the escalating costs and decrease in new drug research productivity, we need to do a better job of getting physician entrepreneurs engaged in the early stages of drug discovery, development and commercialization.

5. Virtuous entrepreneurship The evolution of the cyberintelligence driven economy-the fourth industrial revolution-is forcing everyone, including entrepreneurs, to answer some tough questions.

6. Barriers to digital health physician entrepreneurship It seems that almost everyone who has anything to do with sick care is trying to innovate, move the needle, disrupt, create game changers and win the 4th industrial revolution. It could be a case of too many cooks spoiling the broth.

7. Rookie entrepreneur mindset mistakes. Innovation starts with the right mindset. Doctors who are considering a side gig or an alternative non-clinical career, have a hard time getting their heads around the entrepreneurial mindset. There is a difference between the clinical mindset and the entrepreneurial mindset.

8. How to fake it ’till you make it. The overwhelming number of doctors, engineers and scientists don’t have an entrepreneurial mindset. What’s more, when they have an idea, they don’t know what to do with it since they will not learn those competencies in their formal training. They just don’t know how to innovate their way out of our sick care mess.

9. The myth of patient consumerism The newest mantra in sick care is patient empowerment to make them effective consumers of care. The underlying assumption seems to be that by giving them the information they need, patients will make sick care decisions, and even health care decisions, that are not only in their own best interests, but, in so doing, in the interests of the society at large. Doctors are being asked to do the same thing. Unfortunately, it is virtually impossible to serve three or four masters. The problem is that asking patients to shop for care does not work.

10. Digital health: Stop frying doctors. Another survey showed that doctors are burning out in big numbers, but that some specialties are worse than others. The survey asked about the prevalence of burnout factors and how they affect physicians’ lives. Overall, 42 percent of respondents were burned out—down from 51 percent last year—and 15 percent admitted to experiencing either clinical or colloquial forms of depression.

11. Side gig doctors These days more and more doctors have a side hustle, whether it be a way to earn more money, recovering from a disability, disciplinary action, disqualification, disaster or divorce, or as a pathway to exiting clinical medicine altogether. There are many side gig possibilities.

12. How to pick a residency if you are interested in entrepreneurship Applying for and being accepted to a residency after medical school is a complex, important decision. There are several factors to consider including the reputation of the place, the likelihood you will be accepted, the culture, whether it is a “good fit”, your performance in medical school,where you went to medical school and undergrad, bias,whether you are applying as a couple, the local cost of living, and, the location and lifestyle amenities it offers and how much it pays.

13. So, if patients are customers, how do you sell to them? Consumerization of sick care is on everyone’s lips. I think patient consumerism, i.e. the belief that if given the right information, patient-consumers will make smart sick care choices based on value , is a myth.

14. Why do people still say doctors are lousy business people Despite the many doctors creating user defined value through the deployment of innovation, people still insist doctors are lousy business people.

15. Data competency is the new black Many are predicting the jobs of the future, how to robot proof your kids and what knowledge, skills, abilities and competencies will be key to avoid your white coat getting the pink slip. Communication, creativity, complex problem solving and collaboration are usually on the list. Now we need to add another “C”: healthcare data competency

Here are some other stocking stuffers:

1. Advice to a medical student entrepreneur Congratulations on your recent graduation. I’m sure you are thrilled to start medical school in August and are looking forward to taking a break this summer.
2. Advice to a premed Thank you for inviting me to address your graduating class. I know it’s hot out there sitting in those folding chairs and the pot is kicking in, so I’ll keep this short.
3. The five phases of physician entrepreneurship development Physician entrepreneurship describes the pursuit of opportunity under conditions of uncertainty using scarce resources with the goal of creating significant multiples of user defined value through the deployment and harvesting of biomedical and care innovation. Clinicians are becoming interested for many reasons and they characteristically go through defined stages of their physician entrepreneurship career progression.
4. Fundamentals of edupreneurship Entrepreneurship means many things to many people. Perhaps the biggest misconception is that entrepreneurship refers, exclusively, to starting businesses. In fact, if we use the definition that entrepreneurship is the pursuit of opportunity with scarce or uncontrolled resources with the goal of creating user defined value through the deployment of innovation, then it means much more. In fact, there are many ways to innovate and create user defined value, whether it be in sick care or education, other than taking care of patients, starting a business or teaching students.
5. A boomer’s guide to teaching millennials My parents were traditionalists. I’m a boomer. I work with a lot of Gen-Xers. I teach a lot of millennials. We are all trying to understand each other and adapt to how we teach and learn.
6. Posts on Innovation Excellence

Happy New Year and good luck!

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