At a recent event organized by Harvard Medical School (HMS) affiliated Incite Health to show-case their class of healthcare fellows and their ventures I heard their keynote speaker talk about one the major problems faced by our industry and the innovators trying to disrupt it. His advice came with a lot of gravitas having been part of the healthcare ecosystem at HMS and Merck and various other organizations working on introducing tech-fueled innovation. In his words the plight of the industry and innovators had been with its fateful love affair with pilots, an affliction sometimes referred to as pilotitis.
The word pilotitis cannot be credited to the digital health world. In fact, the mobile health (mhealth) space, which refers to the use of mobile technology in bringing clinical interventions to resource-constrained environments, had already experienced this menace. In low and middle-income countries, where most of the mhealth work has been focused on, novel mobile-enabled health services were often launched but were never rolled out as sustained services supported by policy. The innovators and companies that aimed to bring new products and services to the market usually spend time on the ground to understand the needs for a particular problem. The resulting pilots end up iterating to arrive upon a solution that is right for the given context. However, when it comes to scaling beyond the pilot, the target market for these mhealth solutions are typically public organizations with multiple layers and often at two levels of government which made the decision making process complex and lengthy. Other problems such as spending restrictions, risk-averse culture and outdated procurement processes thwarted innovative solutions from being made available to health practitioners in these constrained environments.
Given the lessons learned from mhealth, it is surprising that the digital health world, which aims to bring complex set of services to patients across various care settings, has fallen for the same ill-fated trap. In some ways the pilot culture is influenced by the public sector. Center for Medicare and Medicaid Innovation (CMMI), which was established under Obamacare, has been force behind launching new delivery and payment system pilots from the government's side. However, these pilots are significant in size and typically last for multiple years. In addition, these pilots are typically only open to organizations or a group that has some direct responsibility for healthcare delivery. These pilots (sometimes referred to as demonstration projects) go through multiple stages of review before opening up an RFP.
In contrast the delivery organizations, which come in various flavors, are the target market for innovators and startups, and hold the keys to the castle. The metric for success for a lot of early-stage companies is the number of pilots that they have been able to launch with these organizations. So much so that the digital health startup ecosystem plays to these metrics as well in attracting participation from provider organizations that want to be perceived as "cutting-edge" and "innovative". That sounds like a great recipe. Almost. It’s not how the delivery organizations solicit pilots, its what that entails for the early-stage digital health companies that wish to participate in it. These pilots are often ill-conceived, run into opposing interests at different levels of the delivery organization, have a very long gestation process which often times comes across as a black box, and is often doomed to failure and hence never scale. It would be one thing if this was a US-centric problem, but there is evidence that this disease is not specific to the US.
While their intentions to bring about innovative digital health solutions are not misplaced, their execution is found wanting. Even if they were to take a page out of the CMMI playbook, it would help to clearly define an RFP process. This RFP process would be derived from organizational or business objectives, against which they can define clear criteria for selecting which pilots get to run. Launching an initiative that doesn’t entirely map to existing clinical practices requires a certain amount of foresight and reserved bandwidth from these organizations.
What is needed is a gate-based approach, which is common to product development organizations that empower inclusion of new or evolutionary ideas, needs to be adopted and made transparent to the early stage companies. A clearly defined and documented process of introducing these innovations needs to be developed and made public as part of the organization’s RFPs. This should involve affording responsibility and structure needed at each level of the organization, from IT to nursing. The spray-and-pray, many-irons-in-the-fire, helter skelter approach part of pilotitis has been detrimental to a lot of young companies and the body bags are only going to pile high if a clear construct to introduce and scale pilots is not provided.