In his 2009 book The Innovator's Prescription: A Disruptive Solution for Healthcare, Harvard Business School Professor Clayton Christensen suggested healthcare was ripe for disruptive innovation.
Outsiders, according to his theory, were more likely to usher in change at U.S. healthcare systems because they had the flexibility to create new business models that make services more accessible and affordable.
But what happens if health systems learned to disrupt themselves? This was uncharted territory, Christensen acknowledged. “The challenges that arise from being an incumbent and an entrant simultaneously have yet to be fully specified; how best to meet those challenges is still to be discovered,” he wrote.
His recommended health systems separate their existing business from internal innovative initiatives. Otherwise, managers would favor innovations that support the current business model with its predictable returns rather than allocate resources to new technologies and approaches where the return was unknown.
The Carolinas HealthCare System, which operates 39 hospitals, is one healthcare system applying this approach. Managers recently spent two weeks at the Clayton Institute. The goal was to learn how to identify new businesses that could sustain the system in the future where technology and new payment models are likely to transform how care is delivered.
The chief strategy officer now oversees two different groups: one focused on innovations that will grow its existing businesses, like out patient surgery centers; and one focused on implementing potentially disruptive innovations.
It is looking for business models that either serve new groups of patients, who had not received care previously, or offer simple solutions in areas that are unnecessarily complex and expensive.
One of the more prominent projects among Carolinas Health's 30 innovation initiatives is a tele-consult, virtual behavioral health program delivered through the system's primary care network, according to Ann-Somers Hogg, innovation director at the system.
Identifying the issue
Anxiety, depression, substance abuse and other psychological ailments affect nearly one in five Americans or 43.8 million people, according to the National Alliance on Mental Illness. Yet behavioral problem often go undiagnosed.
Primary care and emergency room physicians frequently lack the time, training and resources to recognize and treat behavioral conditions, which often present as physical symptoms like insomnia or headaches. About 65% of patients with behavioral health problems leave medical settings without receiving treatment, according to the Commonwealth Fund.
The problem, says Dr. John Santopietro, Chief Clinical Officer for Behavioral Health at Carolinas, is that behavioral health remains a poorly reimbursed, labor-intensive service.
But using telehealth to deliver the service can make it more viable, especially in a reimbursement environment where an increasing share of provider revenue comes from contracts where they're responsible for patients' overall heath. Behavioral problems like depression, anxiety or substance abuse often make it more difficult to treat other chronic conditions.
Carolinas isn't the only system moving into using telehealth to deliver behavioral health services. Others include the University of California Davis Health System, which is using virtual behavioral health services to screen and treat patients. There are a dozen new companies offering remote counseling to primary care doctors and emergency departments.
“There is substantial empirical evidence showing that telemedicine interventions work well for patients with mental or behavioral disorders,” said Dr. Peter Yellowless, a professor at UC Davis, citing finding from his recent study The Empirical Evidence for Telemedicine Interventions in Mental Disorders published Telemedicine and e-Health in February 2016.
Setting the agenda
Executives at Carolinas sought out funds from a philanthropist to support the project, enabling them to bypass the usual return-on-investment constraints.
To figure out what exactly virtual behavioral health could look like and how it would be implemented, the innovation team held what it called design week where primary care physicians, behavioral health professionals, members of the information services team and administrative officers created a prototype of the new service.
The team adapted a model developed by the University of Washington where primary care physicians routinely screen every patient for anxiety, depression and substance abuse. Patients identified for follow-up receive an immediate virtual consult in the exam room.
