By Andrea Mongler
Making Medicine Better
A little boy is cured of cancer. A woman finds relief after months of pain. A man gets the new lung he needs to breathe easy and keep living. A baby goes home from the hospital—healthy after a frightening early birth and a stay in the newborn intensive care unit. With its cutting-edge technologies and lifesaving advances, the field of medicine is full of stories like these. This is apparent every day in health-care systems across the country and around the world.
But here’s what else happens every day: A physician burns out from the long hours and high stress. Someone struggles to navigate the health-care system to get a loved one the help they need. A patient dies from a preventable complication that was caught too late. Scenarios like these are common but fixable—and they’re why the Healthcare Innovation Lab at BJC HealthCare and Washington University School of Medicine exists.
The lab launched in 2017 as a way to identify and test innovations that address a wide variety of problems in health-care delivery. For example, it works on projects to help people access care, to help predict who is becoming sick, monitor patients’ health at home, mitigate supply chain issues and identify and address physician burnout. “The lab was started because of a recognition that the continuing maturation of technology and digital tools would likely be very valuable in the way we deliver care,” says Thomas Maddox, MD, MSc, BJC’s vice president for digital products and innovation. “But the only way to know how valuable is to gather evidence—just like we do with the pills we take and the medical devices we use. The lab was an effort to gather that evidence—and ultimately implement solutions.”
Simple solutions, big impact
Often, the creative solutions the lab finds and implements involve those advanced technologies the field of medicine is known for. But sometimes the lab identifies simple solutions to relatively straightforward problems.
Take the issue of non-emergency medical transportation. After a stay in the hospital or an emergency room visit, many people have no reliable transportation—which could mean no car of their own, no one to pick them up, or no money for public transportation. For these people, a hospital or emergency room discharge doesn’t mean an immediate trip home. It means sitting in the hospital and waiting—maybe for hours.
Understanding that this was a significant problem on the Washington University Medical Campus, Innovation Lab staff got to work. They started by gathering as much information as they could to understand the full scope of the problem. Quantifying the problem was tricky since BJC wasn’t tracking the number of patients affected, but the lab’s best estimate was 16,000 patients a year across the BJC HealthCare system. Maddox says social workers “were trying to Band-Aid the problem by finding little pots of money to pay for a cab.” And he says the median time for those cabs to arrive was between two and three hours. And sometimes they didn’t show up at all.
“It was a source of significant dissatisfaction for patients, it cost money and it was also a hospital-capacity issue,” says Maddox, who also is executive director of the Healthcare Innovation Lab and a Washington University cardiologist at Barnes-Jewish Hospital. “We knew that patients who were having trouble getting home would probably have trouble getting back to the health system for regular clinic visits and things like chemotherapy and dialysis. With that in mind, we started looking for solutions.”
The lab identified a group of companies that provide non-emergency medical transportation. Acting as brokers, these companies work with independent-contractor drivers. The setup is similar to Uber or Lyft, except that some of the drivers have vehicles equipped to transport people with medical issues; they may have oxygen tanks or wheelchairs, for example. Like Uber and Lyft, the broker companies provide a digital platform that social workers can use to hail rides for patients.
The lab decided to partner with one of these companies, and the results are telling. The requested car shows up more than 90% of the time, and the median arrival time is just nine minutes. BJC has now expanded the program to include transportation for people with cancer to their appointments at Barnes-Jewish Hospital and other BJC HealthCare facilities, and the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.
To date, the program has provided more than 12,000 rides. Maddox says that both patients and clinical staff have been pleased with the program, and it has generated positive financial returns via improved inpatient and emergency department bed turnover, reduced administrative time to coordinate rides, and improved “show” rates for outpatient visits and procedures. For BJC and Washington University School of Medicine, the program has been a clear success. For the Healthcare Innovation Lab, it’s all in a day’s work.
A model for innovation
Maddox says the lab’s process of identifying potential areas of improvement in health-care delivery is structured, yet it also accommodates the process of learning and adapting that occur with any new endeavor. To guide its efforts, the lab has adopted a process from the design industry that includes the following steps:
1. Discover. Observing the problems people encounter in receiving health care
2. Define. Selecting a specific problem and determining how improvements will be measured
3. Develop. Considering all possible solutions to the chosen problem
4. Deliver. Choosing the solutions that make sense, testing them and collecting measurable information
The lab’s director, Ali Kosydor, notes that this process allows the team to take a “broad but intentional approach to considering the world of possibilities to help solve a problem. And because we’re applying the framework in a health-care environment, we’re putting the patient perspective at the center of this process.”
Fostering the right culture
A key part of Maddox’s and Kosydor’s jobs is to keep up to date on innovations across the healthcare industry and beyond. That means, for example, paying attention to emerging technologies, staying in touch with other health systems and attending health-innovation conferences. They also get ideas from much closer to home through the Big Ideas grant competition. Sponsored by the Healthcare Innovation Lab and the Washington University School of Medicine Institute for Informatics, Big Ideas gives teams at BJC and the School of Medicine an opportunity to compete to have their own projects funded. Maddox says they receive between 30 and 40 applications each year. Selected applicants pitch their ideas during a live event. Six winners are selected, and they each get a grant of $50,000 to test and implement their projects.
“Through the Big Ideas competition, we gain the knowledge and skill sets of our academic partners at the School of Medicine and also clinical expertise from BJC staff,” Kosydor says. “We benefit from their comprehensive and diverse experiences and knowledge, which really sets us apart in the innovation ecosystem.”
In 2020, one of the winning Big Ideas projects focused on increasing use of palliative care for patients nearing the end of life. Palliative care primarily involves symptom and pain mitigation to keep people comfortable and improve their quality of life. But use of palliative care is low; less than 2% of inpatient admissions within the BJC HealthCare system receive palliative care services annually.
So when Patrick White, MD, director of the School of Medicine’s Division of Palliative Medicine, heard about the Big Ideas competition, he saw an opportunity to increase use of end-of-life palliative care at BJC hospitals. White and colleague Nathan Moore, MD, an internal medicine physician at BJC HealthCare, used their Big Ideas grant funding to monitor data from BJC inpatients and—based on carefully selected criteria—determine which patients were likely nearing the end of life. When they identified such a person, they reached out to the inpatient care team to ask whether someone had initiated a conversation with the patient about their goals for care and whether the palliative care team could help.
Maddox says White and Moore identified more than 400 people and had a 90% response rate from teams, most of whom hadn’t previously had a conversation with a patient about personal goals for end-of-life care. Of those, 60% then initiated a conversation, resulting in 25% of the patients having a significant change in their care plans. Today, a new process is in place that helps more patients access palliative care in eight BJC hospitals, including Barnes-Jewish Hospital, with plans to expand across the 14-hospital BJC HealthCare system.
“This is such a great example of how important it is to foster an innovation culture,” Maddox says. “Through the Big Ideas competition, we’re giving people who have an idea they’re excited about an opportunity to see if that idea has any legs. In this case, the result is that we’re respecting people’s wishes at the end of life and helping to make whatever time they have left as meaningful as possible.”
Training future innovators
The Healthcare Innovation Lab also provides opportunities for trainees, including medical students, residents and fellows. For example, the lab offers an innovation fellowship that gives senior fellows or early-career faculty members a chance to spend a year working on innovation projects at the lab. “Our fellows become familiar with the overall process of innovation and also get training that informs the rest of their careers,” Maddox says.
In addition, through a pathway offered by the School of Medicine, medical students can work at the lab as an elective. In fall 2021, three students worked on an inpatient sleep-optimization project—an effort to find solutions to the problem of poor sleep among hospital inpatients After interviewing patients and observing processes that disrupt sleep in hospital rooms, the students synthesized their findings into a graphic that illustrated all the identified barriers to sleep (see the illustration titled “The Problem”). These barriers included noise levels, room lighting, semi-private rooms, room temperature and clinical staff interruptions. “This was such a creative way to define and represent the problem,” Maddox says.
The students also grouped potential solutions into two categories: workflow and environment. Within those categories, they identified each potential solution as low, medium or high “lift,” indicating the degree of effort and cost to implement. The students’ next step will be to determine which solutions to test.
“We love giving medical trainees an opportunity to step outside of the classroom and exam room,” Kosydor says. “We’re challenging them to think about new ways we can better serve patients—and in turn, they’re challenging us to think differently from how we’ve operated in the past.”
Beyond hospital walls
The Healthcare Innovation Lab’s work extends beyond BJC inpatients, ultimately “providing better care for our community” more broadly, as Maddox puts it. For example, the lab worked with BJC and Washington University teams in information technology, virtual care and clinical care to develop a home-monitoring program for ambulatory, homebound people with COVID-19. Participants received a thermometer and a pulse oximeter so they could measure and record their own temperatures and oxygen numbers. They submitted this information as part of a daily questionnaire they received through an app—or gave their information orally to nurses via a phone call if they didn’t have a smartphone or preferred to get calls.
Interestingly, some patients with COVID-19 preferred the phone-call option even if they did have access to smartphones and other digital technologies. Maddox says that when these participants were asked why they chose phone calls over an app, many said they were scared and isolated, and simply wanted to talk to someone.
Nurses monitored patients’ information every day, and if they saw signs indicating someone was getting sick enough to need hospitalization, they’d take action to get the person into the hospital right away. To date, the program has monitored more than 16,000 patients; 13% required emergency department care and 7% required hospitalization. “Through the home-monitoring program, we identified a number of patients who needed help,” Maddox says. “The program allowed us to stay in touch with patients and respond quickly when they needed additional care.”
Expanding the reach
As Maddox and Kosydor look to the future, they highlight two areas of focus for the Healthcare Innovation Lab. The first is to find ways to provide home care for people with acute conditions that have traditionally required hospitalization—pneumonia, for example. “This ‘hospital at home’ concept really aligns with patient preferences related to speed, access, quality and cost of care,” Kosydor says. “It’s important that we react to these preferences to provide a customer-centered approach to delivering health care—and innovation science is pushing organizations to think this way.”
Maddox says the lab will also begin to focus on improving communication between patients and care teams to help patients better understand their conditions and their treatment. Finally, Maddox says he hopes to expand the lab, adding program managers so that the lab can investigate more problems in health-care delivery—and identify and implement more solutions.
“So far, 18 of the projects we’ve completed have resulted in clinical or financial benefit,” he says. “If we could double that number, we’d be providing that much more benefit to our patients and our community.”