NURSING AND EMERGING TECHNOLOGY
Due to the pace at which technology is being developed, used, and is evolving, there is an expedited need to better manage patient populations (to impact quality of care and outcomes), reduce costs, improve patient satisfaction and engagement, and enhance the well-being of practicing clinicians—the four dimensions of the Quadruple Aim in healthcare (Bodenheimer & Sinsky, 2014; see Figure 1.1). Nurses are key players in driving these imperatives and impacting value-based care through the use of ETs.
The rapid evolution of technology shapes our world and lives. Similar to society, healthcare is now deeply connected to computers. What were once novel ideas, care models, and devices—and new treatments that influence how nurses manage care at the bedside, lead, teach, and research—are now commonplace in hospitals, clinics, virtual care environments, and in nursing education, and have improved the healthcare industry and the nursing profession. Today, technology buzzwords abound—Big Data, Artificial Intelligence (AI), Predictive Analytics and Machine Learning (ML), Virtual Reality (VR), Augmented Reality (AR), Blockchain, Precision Health, and the Internet of Things (IoT). These technologies, while not new in other industries, are increasingly being used in healthcare because of their potential and proven value. From a global scale to the bedside, and spaces in between, an acute need exists for a better understanding of revolutionary scientific inventions by nurses who practice, lead, and educate. Nurses hold all the aces to adopting ETs and using them in the point of care, both in the nonclinical setting and in the classroom setting. The instinct and drive to utilize and adopt technology to communicate better and complete tasks for safe, quality patient care make nurses natural innovators in practice, leadership, and education. In healthcare information technology (IT), this exceptional asset should be at the forefront to develop the necessary standards, security, equity, and policy needed to use ETs wisely.
Figure 1.1
The Quadruple Aim framework.
DEFINITIONS OF EMERGING TECHNOLOGY
Understanding what makes a technology emerging is imperative to discerning past, present, and future in the development of technological innovations. Before delving into the specific ETs in healthcare, it is imperative to define what the words mean both individually and cohesively. Specifically, it is important to identify what each word represents and how they have been synthesized to become relevant in this text’s focus, as well as their use to optimize nursing care delivery in the industry of healthcare. Knowledge of multiple definitions, many still evolving due to the speed at which technologies are developing and implemented, is needed to begin to explain what ETs are, as well as denote their business presence and value, complexity, misconceptions, and acceptance.
Various definitions have been put forth for ETs (Halaweh, 2013; Rotolo, Hicks, & Martin, 2015). A key challenge is that the term is, in many cases, not well defined and lacks understanding (Halaweh, 2013). When we break down the words, the term emerging denotes just coming into prominence. The definition of “technology” is the application of science for the use of practical purposes in a particular industry, with technology being the equipment and machinery developed from the application of that scientific knowledge. It is the tributary of knowledge addressing both engineering and applied sciences. Together these terms define the scientific inventions now used in industries across the modern landscape to help people complete tasks, communicate, make decisions, and find answers. These use cases are essential in healthcare and nursing to give patients the best possible care experience, safety, and outcomes. While definitions of the term emerging technology vary widely, together they form a whole expression that denotes novel scientific knowledge that is becoming less futuristic and closer to reality.
Evolving definitions of ET within the last two decades studied by Halaweh (2013) weigh the notions of Day and Schoemaker (2000), Stahl (2011), Srinivasan (2008), and the Business Dictionary (“Emerging Technologies,” n.d.) and their multiple definitions posited in the last 20 years. There is a clear dissonance, with each based on the industry that uses the technology. This author asserts that the researchers have had a different view on what ETs are from the simplistic to those confined by social necessity and time frames (Halaweh, 2013).
One definition states that technology is emerging if it is not yet essential to possess by a person or user (Millea, Green, & Putland, 2005). Day and Schoemaker (2000, p. 2) and Srinivasan (2008) define ETs as “science-based innovations with the potential to create a new industry or transform an existing one.” Another definition is that ETs are new technologies that are in development or will come to fruition over the next 5 to 10 years and will substantially alter major industries and society (“Emerging Technologies,” n.d.). A different definition of ETs is that they must have the potential to gain social relevance within the next 10 to 15 years, with the notion that they are not only present at an early stage in development, but they have already moved beyond the purely conceptual stage (Stahl, 2011). In considering and recognizing these definitions, Halaweh (2013) asserts that ETs lack research; they do not consider social-economical and geographical contexts, including developmental costs, nor availability in certain countries as well as obvious impacts not present at the inception of technology development. These definitions of ET have come from different industries and have changed over time.
Technologies in our age are rapidly changing with new scientific-based products, services, and models at every corner. Definitions of ETs not only appear in scientific literature but also print and electronic newspaper stories, blogs, social media, and vendors. While there is variation, lack of consensus, and mass evolution of thought and theory about what makes a technology emerging, there is one standout definition that delineates aspects of what is becoming apparent scientifically in mature industries today. Rotolo et al. (2015) completed a literature review of innovative critical studies on the topic and developed a concise and meaningful term. They define “emerging technology” as “science-based machinery that is characterized by a certain degree of coherence persisting over time and with the potential to employ a considerable impact on the socio-economic domain(s) which is observed in terms of the composition of actors, institutions and patterns of relations among those, along with the concomitant knowledge production processes” (Rotolo et al., 2015). Further, these researchers assert that the most significant impact of ETs lies in the prospects of technology coming into consciousness, with the emergence phase being uncertain and ambiguous.
This definition asserts that ETs have five essential characteristics: radical novelty, fast growth, coherence, noticeable impact, and uncertainty and ambiguity (Rotolo et al., 2015), with the most prominent influence exerted by ambiguity in the nascent field of ETs. Furthering the influence of ambiguity as an apparent, divergent trait of ETs are the conflicting values and meanings attributed to them by society (Mitchell, 2007).
The defining features of ETs are complex and show that radical technological innovations at the core functioning of modern industries include, but are not limited to, furthering the improvement of practices, building sustainable products, enhancing processes, and stimulating and solidifying thoughts to advance scientific development. With this understanding of what ET means, it becomes clear that healthcare is a sector where novel technologies can be conceptualized, modernized, developed, evolved, and implemented. The use of ET improves quality and safety, decreases inefficiencies and waste, and standardizes care inclusive of all populations and communities to complement existing technologies.
Ambiguity: An Essential Factor in Emerging Technologies
Drawing on Rotolo et al.’s (2015) study and definition of ET and Adner and Levinthal’s (2002) conception that the growth, development, acceptance, and adoption of new technologies is a significant factor in application, the healthcare industry is a business with multiple products, services, and models ready for disruption as ET is developed and used. It is projected that, in 2021, AI alone will generate $2.9 trillion in business revenue and recover over 6 billion hours of worker productivity in many industries (Gartner Newsroom, 2017). A movement forward with evolving and revolutionizing the business of healthcare for better physical and financial health without fluidity and divergence in thought is an obstacle for health IT users. One might argue that while there is a place for ETs in healthcare, the traits and factors that are advancing them into evidence-based practice, as previously defined—particularly ambiguity—should be avoided for safety, quality, and ethics purposes. In truth, these factors spark innovation. It is essential in an industry fraught with big problems to seek answers to solve them. In the conceptualizing, evaluating need, development, and testing phases of new technologies, diverse perspectives need to be considered, and flexibility and comfort with the unknown embraced despite incongruency. With this acceptance, the crucial questions and problems that need answers and fixing will come to light as we develop ETs in healthcare.
INNOVATION, DISRUPTION, AND HYPE
Definitions for ET present the case that novel technologies go through periods of evolution and revolution. The underlying revolutionary emergence of new technologies is often a process of shifting territories of usefulness and rapid subsequent growth in unchartered domains and how they change over time; also, the pace at which new technologies are developed, accepted, and adopted is a significant factor in technology application (Adner & Levinthal, 2002). This process requires both innovation and disruption. The terms innovation and disruption are used in multiple industries, synonymous with ETs. However, the definitions are not fully understood and can be overused to simplify the existence of new technology and a sense of blind optimism of what they can and will do, rather than their actual bearing in the marketplace.
Innovation
Today innovation refers to a novel solution that solves a problem. The technology industry and society use the term “innovation” readily. It denotes “the latest and greatest thing” that meets the needs of a rapidly evolving world dependent on technology and is used to competitively develop new ideas, inventions, and services that add value, leading many to instantly refer to these products, services, and solutions as innovation (O’Bryan, 2017). With the enormous need for radical technological solutions in banking, telecommunications, retail, and automotive industries, U.S. Commanders in Chief have put technology innovation initiatives into their policy agenda. One focus of the Obama Administration’s 2016 $215 million budget for “Strategy for American Innovation” was to fund a healthcare program to advance the ET of precision health and genomics through managing and analyzing Big Data sets, furthering health IT while developing methods for increasing health data privacy (The White House, 2015). Likewise, the Trump Administration has held talks with top technology companies to begin discussions funding AI research partially aimed at the U.S. economy and the workforce (Simonite, 2018).
While innovation is what ETs stand for, the term “innovative” is what the novel idea, product, or service is, with a lack of another word for description. As a society and within industry, we speak of “innovation” readily as the endpoint and “innovative” as an adjective to describe something novel. However, in the sectors that create revolutionary solutions, innovation should be deemed instead as a series of separate proficiencies and actions (O’Bryan, 2017). Viewing innovations in this manner rather than in terms of what technology is needed will truly revolutionize and evolve novel technologies rather than generalize them by those who use the term—those who conceptualize, create, use, and fund novel solutions such as inventors, vendors, customers, and investors.
Disruption
Along with innovation, “disruption” and “disruptive” are used to describe the vast revolutionary impact innovations have on industry to effectively move the needle for solving modern customer problems and evolve business models. Disruption is an innovation that creates a new market and disrupts an existing market and traditional business practices. It explains what the innovation or ET needs to do to make it change and truly transform and modernize a marketplace. In 1995, the brainchild of innovation theory, Clayton Christensen, whose schema has been called the most influential business idea in recent years (The Economist, 2017), pronounced disruptive innovation as an arm of innovation theory, along with sustaining evolutionary and revolutionary innovations (Macfarquhar, 2012). His work asserts that disruptive innovation is one that spurs a disruption towards current existing products, market and value networks to subsequently stimulate new markets and business niches (Ab Rahman, Abdul Hamid, & Chin, 2017).
Disruption is an essential element to measure the vast change and growth innovation has in various industries. The terms together illustrate the extent to which advancements deconstruct a marketplace—and not only technology. Christensen (2018) describes disruptive innovation as “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors” (para. 1). Evidence of disruptive innovation over the last few decades can be seen in healthcare, where clinician communication, care delivery, standardized practices, and payer models have revolutionized the way in which healthcare is practiced. See Table 1.1 for “disruptors,” those that created a novel healthcare product, service, and solution, and the “disruptee,” the healthcare business models that have been transformed, and their impact on the Quadruple Aim.
As Table 1.1 represents, newer technologies in healthcare have disrupted or discontinued technologies that once were thought of as revolutionary in care delivery, such as the need for pagers to communicate among care teams, reading radiology results, and ways of documenting clinical data and information. They have evolved in the healthcare marketplace, with technological discontinuities not being a product of any particular event in the development of it, but often an evolutionary event, shifting the existing technology to a new territory where it evolves in new directions—that novel technology, or set of technologies, may be applied to a new area of application (Adner & Levinthal, 2002), in this case, healthcare.
Table 1.1
“Disruptors” and “Disruptees” and Their Effect on the Quadruple Aim in the Healthcare Industry
| Disruptor | Disruptee | Business Model Transformed | Quadruple Aim Impact |
|---|
| Retail clinics | Primary care | Ambulatory care | Patient satisfaction |
| Accountable care organizations | Third-party payers | Health insurance | Controlling cost |
| Electronic health records | Paper charts | Clinical documentation | Clinician experience |
| Wearable, voice-controlled, wireless badge | Telephone or pager | Telecommunications | Clinician experience |
| Urgent care clinics | Emergency rooms | Hospitals | Care quality |
| Worksite wellness clinics | Primary care | Hospitals and clinics | Patient satisfaction |
| Remote monitoring | Intensive care | Hospitals | Controlling cost |
| Virtual care | Patient visits | Hospitals and clinics | Patient satisfaction |
| Robotics | Surgical care | Care delivery | Care quality |
| Simulation | Medical education | Education | Controlling cost |
| Picture archiving and communication systems | Radiology | Care delivery | Controlling cost |
| Advanced nurse practitioners | Physicians | Care delivery | Care quality |
| Mobile handheld tablets | Paper charts | Clinical documentation | Clinician experience |
Disruptive Innovators
Another buzzword in modern terminology concerning new technologies and business models is the term “disruptive innovators.” While disruption has a general derogatory nuance of interrupting or being problematic, the connotation has quite a different meaning for forward-thinkers in business. This term has been coined to identify key players in business and industry who elicit visionary behaviors in their approach to developing, championing, adopting, and utilizing new evolving processes and practices, by design, or intentionally using innovation theory in business to facilitate innovation. These revolutionists are the crucial resource for not only inventing ideas to diffuse and support innovation development but also to realize, further adopt, and sustain them. Five synergistic skills are distinct in disruptive innovators: having the ability to create novel products by linking ideas previously unconnected to solve problems; persistent questioning and observing and being fervently experimental (Dyer, Gregersen, & Christensen, 2011). Disruptors harness these skills to think differently and bring new products, services, and models to fruition. In light of the innovations in healthcare, disruptive innovators certainly exist in the industry. As ET evolves rapidly, visionaries, inventors, implementors, and researchers with these traits will change evidence-based practice and be relentless to revolutionize the future of the health of individuals and all populations not only at the macro-level but through further innovations at the point of care (Case Study 1.1).
CASE STUDY 1.1
A PRIMARY CARE GAME CHANGER: VERA WHOLE HEALTH
Disruptive healthcare delivery models surfacing around the country are serving a need for healthcare that focuses on time savings and convenience to maximize cost savings and patient-centered health engagement for improved outcomes. The exposure to a new model that provides a supplemental option for flexible full healthcare services for both employers and employees is beginning to change traditional primary and specialty care and payer models—direct-to-employer advanced primary care (Patient-Centered Primary Care Collaborative, 2018).
Vera Whole Health, a Seattle-based company offering on-site and near-worksite advanced primary care centers, is changing models of healthcare delivery as an alternative primary and specialty care provider. With the high cost of urgent care center, emergency department, and specialty care visits in today’s value-based care landscape, this new model of care delivery provides holistic care to employees in a medical home structure to increase employee health engagement and lowers employee out-of-pocket healthcare costs, as well as costs to employers. The innovative care model for full-service on-site advanced primary care works by charging an employer a per member per month (PMPM) fee for care services in addition to employee health benefits, without co-pays, deductibles, or additional fees to access Vera’s advanced primary care centers. The employee or plan-funded model removes third-party payers from these care transactions and transforms the traditional health insurance framework for primary care and specialty care, saving employers a significant amount of money with centrally located care centers offering multiple health services (R. Schmid, personal interview, December 19, 2018).
In today’s “now economy” healthcare expectations, Vera Whole Health’s model meets healthcare consumers’ needs, improving their overall care experience. With Vera’s board-certified providers, wellness coaches, telehealth services, and website portal and app, patients can be seen sooner for all types of conditions in one care center to circumvent the need for expensive urgent and specialty care. The flat fee to employers for full-service primary care encounters includes preventative health screenings and biometric testing for employee wellness incentives. And, in conjunction with the provision of acute care services for minor injuries and illnesses, travel medicine, immunizations and pharmacy, occupational health, vision, rehabilitation, behavioral health services, and basic disease management (Vera Whole Health, 2019), this model is a game changer in a fragmented healthcare system.
Leading the direct-to-employer primary care provider marketplace in the Western United States, Vera Whole Health employs physicians and nurse practitioners in a patient-centered medical home care delivery framework. They offer wellness coaching for health behavior modification, ensuring whole person-centered care and enhanced patient health engagement. The medical home model enables the company to implement a population health management strategy, to track and build care plans for all employees, and target the sickest patients to address their essential needs to improve health outcomes. Vera’s comprehensive care center model supports better access to care with same-day appointments and timely follow-up encounters which are becoming difficult for many patients to adequately secure with primary and specialty providers, mitigating costly emergency and specialty care services for considerable savings to employers.
In Western Washington, the City of Kirkland launched its Vera Whole Healthcare centers to optimize its employee health benefits strategy in 2015 to decrease healthcare costs and improve long-term health outcomes for their employees. Vera’s adjunct care delivery service enabled the employer to achieve a 90% employee engagement rate in 12 months, leading to a 25% reduction in claims and 15% net savings in overall healthcare costs, and decreasing the city’s number of employee claims trend within 2 years (Vera Whole Health, 2018). Furthering their disruptive model throughout the United States, Vera Whole Health now has 19 care centers in eight states, and they are partnering with Blue Cross and Blue Shield of Kansas City (Blue KC) to operate advanced primary care centers under the name Spira Care Centers in Missouri. Spira Care is a combined primary care and health insurance offering available exclusively to eligible Blue KC members for the care centers in the state. The partnership is a sign of persistent healthcare model transformation between payers and worksite advanced primary care centers to further the creating of new, collaborative care models that prioritize primary and specialty care for employee health engagement to improve lasting health outcomes and to lower staggering healthcare costs around the country (R. Schmid, personal interview, December 19, 2018).
Innovation and Hype
As nurses learn about the terms associated with ETs, how they revolutionize business models, the importance of customers’ demands, and expectation of ETs is clear. The notion of ETs is stimulating both to the ear and imagination, but the terms themselves can be overused. The terms “innovation,” “innovative,” “disruption,” and “disruptive” may lead us to believe that anything is possible with ETs and that anyone in the realm is an expert. This notion can result in the hype and lofty expectations about what ETs are and what they can do for us (Lucker, Hogan, & Sniderman, 2018). Hype can be defined as extravagant or intensive publicity or promotion. The attention in the news and social media related to innovations, including vendor advertisements, blogs, and articles that stop at addressing the function of ETs, can create a false reality of their use and outcomes. In truth, the creation of disruptive innovations takes time, as they are dependent on the development of ideas, needed use cases, the abilities and numbers of skilled developers, and the success of their utility. These innovations are developed rapidly, possibly too quickly, based on customer demands and modern societies’ “now economy.” Inflated promises and ideals of the purpose and expectation of how ETs will serve us can lead to failure as well, and those can many times go unnoticed. Many developers of novel technologies claim to have the latest and greatest product, and many people erroneously refer to themselves as “disruptive innovators.” They merely speak of the promise of innovation and what it may do for nurses without proving its value and using innovation theory to disseminate it. However, talk and speculation are not enough. Diffusion of hype through skepticism and education is imperative. Valuable outcomes of ETs can become certain, given time, market demand, and proof of actual return on investment. Having the right mind to cultivate innovations and disseminate them will move us from hype to reality in the creation and use of ETs.
HEALTHCARE AS A TECHNOLOGY INDUSTRY
Today all companies are technology companies, as no business can develop, market, or deliver services and products and introduce new models without it (Stone, 2017). Healthcare as a business is no exception, one where ET abounds with some of the top 10 technology companies (Stoller, 2018), including Apple, Samsung, and Microsoft, aiming to lead disruptive innovation in the industry (Huynh, 2018). Apple, Inc., known for desktop and handheld computers, music services, and smartphones, is working on enhancing the usability of its ever-evolving consumer-facing products to mimic medical devices. Several of their new products and devices are aimed at tracking diseases, sharing and trending clinical health data, detecting abnormal patient vital signs and physical movements, and allowing payment directly from their devices for medical services (CB Insights, 2017). Samsung, with a historically enormous presence in telecommunications, home electronics, and household appliances sectors, has a health division also focused on consumer wearables to enhance the patient experience. Their immersive device offering uses VR to distract patients from pain during medical procedures, diagnose and manage mental health and neurological disorders, and provide therapeutic rehabilitation technology to improve care quality and cost (Muoio, 2018). Microsoft, the world’s largest microchip maker, also aims to be a leader in healthcare innovation. By leveraging of HIPAA-compliant cloud computing for data management and security, the company now offers predictive analytics and ML aimed at improved precision health, enhanced clinical decision support, and reduction of clinical documentation for healthcare providers (Bresnick, 2018b). Together, these three top technology companies are moving into the healthcare marketplace to offer digital health solutions aimed at a full-service connected care continuum for the patient focused on health and well-being while reducing costs, managing populations, and improving healthcare to improve the clinician experience. The collaboration between researchers and health systems can have a high impact on value-based care and the Quadruple Aim.
While large-scale IT companies are getting the most attention in their disruptive products, services, and prototypes in the healthcare space as they attempt to transform it with their business models, smaller healthcare companies are cited as true disruptors in the healthcare IT sector. CVS Health’s pharmacy services; genetics-based testing companies including 23andMe, Color, Veritas Genetics, and Helix; and high-risk patient care management apps Glooko and Emocha Mobile Health are among these healthcare technology companies (Fast Company, 2018). These retail businesses and smaller companies are truly patient-centered, with a focus on patient engagement and connected health to serve all arms of the Quadruple Aim, working to deliver healthcare services, products, and models that modernize care delivery based on healthcare provider and consumer demand, thereby enabling better data transfer, customer convenience, and precision care.
In 2015, CVS opened an innovation lab to develop services for its customers to enable smartphone text reminders for refills and barcoding prescription technology at the point of service for faster, more convenient processing of new and refilled prescriptions (Castellanos, 2017). The demand for company offerings of 23andme, Color, Veritas Genetics, and Helix stems from a mass market of consumers curious about inherited health and what they can do with the knowledge of it. These companies offer direct-to-consumer testing kits that analyze DNA for ancestry discovery, disease hereditary testing, and disease prediction, without a healthcare provider’s order (National Institutes of Health—U.S. National Library of Medicine, 2018). Affordable, comparative to laboratory testing, self-testing kits offer genetic data for personal use to further genomic research for rare and common conditions such as cancer and heart disease with the intent to enable consumers to understand their health risks better and use the data for personal, preemptive, and precision health (Bresnick, 2018a). Glooko, a diabetes care management app-driven tool that interfaces with many home glucose monitors, insulin pumps, and exercise trackers, sends patient data directly to his or her healthcare providers, with a web interface that shows the trends of the patient’s glucose levels and makes recommendations for diet food and exercise to help manage the chronic condition (Lovett, 2018). Emocha is a mobile app that aims to monitor medication adherence in high-risk populations including those with HIV, tuberculosis, and hepatitis C through video directly observed therapy (VDOT; Wicklund, 2018). A study of TB patients using the Emocha app resulted in increased medication compliance, with researchers recommending the platform for utilization in medication management of high-risk patients requiring regularly scheduled therapy to improve patient-centered care and cost savings (Holzman, Zenilman, & Shah, 2018).
Partnering for Healthcare Innovation
Because hospitals, clinics, and their administration lack the innovation leadership, know-how, inspiration, and ideas to disrupt their healthcare system business models effectively to improve value-based care, many are looking for healthcare technology industry innovators to partner with them. This emerging trend partners organizations with big technology players and start-ups—new small companies focused on a specific industry business problem to solve: to spearhead innovation (Gaskell, 2017). Together, healthcare organizations and leading-edge technology innovators aim to disrupt their business models by collaborating to rapidly develop products and services to transform patient care with the intent of improving quality and safety, and reducing costs. In tandem, resources pooled from these divergent collaborations foster new ways of thinking to conceptualize, build, test, and implement novel technology, and sustain innovation within the healthcare organization (Zand, 2017). This radical approach is successful when talent outside of a healthcare organization brings ideas and an innovative spirit for the invention of using technology to its fullest extent and reaching even further beyond to invent new models and use existing technology in different ways (Gaskell, 2017). In many cases, this has led to the establishment of innovation centers within healthcare organizations focusing on multiple innovation projects that use ETs as a cornerstone of new products, services, and models. They have also resulted in establishing health-focused start-ups and spin-offs in healthcare IT—organization, university, or research institutions who develop their own companies and businesses. See Figure 1.2 for a depiction of how these relationships work.
Healthcare Innovation Centers Advancing Emerging Technologies
With disruptive innovation now common in the healthcare industry, the fruits of divergent collaborations between vendors—the big IT players, and start-ups and spin-offs—and healthcare organizations are essential to catalogue and disseminate innovation knowledge, products, and processes to hospitals and healthcare systems who need education to build innovations and disrupt business models.
Figure 1.2
The process of divergent collaborations.
IT, information technology.
In a survey conducted by the American Hospital Association (AHA), close to three-quarters of large healthcare organizations have either built an innovation center or have plans to build one soon (Sullivan, 2017). These centers are becoming businesses themselves, patenting their inventions developed in the labs for mass distribution. Multiple entities, from healthcare organizations to medical health IT associations, have embarked on the journey to establish hotspots for the creation and dissemination of innovative solutions and knowledge across the globe.
The Cleveland Clinic, one of the pioneers in the creation of healthcare innovation laboratories, has had significant success with its innovation center, Cleveland Clinic Innovations (CCI), established in 2000. Since then, with divergent collaborations and a strong commitment and culture dedicated to innovation within their institution, they have invented over a thousand licenses and issued patents and created over 40 spin-offs (Cleveland Clinic Innovations, n.d.). The CCI now holds innovation events, summits, and presents awards nationally for healthcare innovations—medical devices, new treatments and procedures, and uses of ETs, such as AI and VR, and precision health.
The AHA has followed the healthcare industry’s transformation trajectory and established the Center for Health Innovation in 2018 (AHA, n.d.). The AHA intends to use innovation to test new payment and delivery models, better utilize IT and data, and develop the leadership skills and competencies necessary to transform healthcare by identifying novel ideas and opportunities and implementing them (Slabodkin, 2018). The intent is to assist hospital and health systems to build new advances at scale to transform value-based care.
The Healthcare Information and Management Systems Society (HIMSS), a global, cause-based, nonprofit advisory organization that supports the transformation of health through the application of information and technology (HIMSS, n.d.-a), has also developed a proprietary innovation lab. Built to host events focused on developing health information technologies, the Center is a hub to bring IT industry leaders together to convene and confer about healthcare innovation at all levels of maturity to educate the public about disruptive technologies (HIMSS, n.d.-b). In 2018, they acquired Healthbox, a leader in health innovation consulting to further the abilities of healthcare organizations by developing the tools to bring healthcare innovations into their systems and help manage funding for disruptive technology projects (Sullivan, 2018).
Conscientious Innovation
In healthcare, clinicians are held accountable for promoting safety and quality (The National Academies of Sciences, Engineering, and Medicine, 2018) and mitigating implicit bias in the care of patients (The Joint Commission, 2016). Health IT that revolutionizes the way we practice and impact people, populations, and communities needs the same layer of safety, quality, objectivity, and fairness in the advancement of disruptive innovations such as ETs. With the new reality and focus on divergent collaborations that expedite new technology-based products, services, and models, careful consideration should be given to why, how, when, and where we develop new scientific advancements (Browne, 2018). The real value of technical development, transparency, and interpretability of functionality, truthful marketing, and proof of return on investment of ETs is imperative to the ultimate end users—patients, clinicians, administrators, and society at large. Developing innovations to disrupt business models with the aim of “Rush to Market” services, products, and new models that serve the Quadruple Aim can be misleading, and not representative of those intended. In the conception, feasibility, assessment, development, testing, and validity phases of disruptive innovations, the human elements of design, usability, and experience need close consideration (Lehoux et al., 2014).
If ambiguity is an essential component of novel technologies, as is the speed at which they are developed and implemented, essential societal fragments get forgotten and lost in an inventor’s and developer’s consciousness and approach, leading to an explosion of ethical concerns. Human representation, well-being, impact, and accessibility need careful reflection during the conception, evaluation, development, testing, employment, marketing, and research of ETs.
U.S. Food and Drug Administration: Taking Steps to Protect Patient Risk With Medical Device Innovation
In 2016, the U.S. Food and Drug Administration (FDA) founded the patient and clinic-focused National Evaluation System for Health Technology (NEST) initiative, aimed at the medical device industry, whose mission is to leverage the experiences of patients to inform decisions about medical device safety, effectiveness, and quality to promote public health and support optimal patient care (Daniel, Colvin, Silcox, McClellan, & Bryan, 2016). In 2018, the FDA announced the first device safety pilot using NEST would focus on women’s health, specifically to develop a surveillance system using data to monitor the effects of the implantable devices to enhance post-market safety (FDA, 2018a). That same year, the FDA’s Center for Devices and Radiological Health (CDRH) released the Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health (FDA, 2018b), which outlines how the agency will incite innovation to enhance safety, detect safety risks earlier, and keep clinicians and patients better informed. The plan modernizes methods to improve measures for the safe use of medical devices while continuing to create more efficient pathways to bring lifesaving devices to patients, with the vision to create a medical device safety net that supports innovation of new products that are safer, more effective, and address unmet medical needs (FDA, 2018b).
Health Disparities and Emerging Technology
Community and cultural impact differ in the onslaught of disruptive innovation and can be a victim of untoward outcomes, neglectful of receiving the benefits of disruptive innovation. The influence on society requires deep reflection. As we move forward with our rapid developments, transparency, unrelenting testing, substantial inquiry, and scrutiny are needed. The fruits of these healthcare innovations must be inclusionary and reach all of society for optimal outcomes. Cultural and ethnic diversity that is forgotten makes ETs moot and unforeseen consequences will abound. For instance, the data that feed ET must be inclusionary of all demographics and free of bias—aimed to represent and serve all populations and demographics equally (Gershgorn, 2018), as it determines the way that people are, or are not, affected by innovation (Adner & Levinthal, 2002). In healthcare, intangible elements such as socioeconomics and the way that people present, perform, and live in their environment cannot be discounted in the development and use of technology; currently, people are increasingly trying to collect and analyze these elements (Correa-de-Araujo, 2017). Through successfully including these structures that can now solely be physically assessed and managed through human interaction, accurate representation and benefits of innovation have a better chance of being realized for all.
The Social Determinants of Health
In data, the features at the core of ET functionality, unknown public health factors and the Social Determinants of Health (SDoH), are elements needing careful inclusion in the inception and implementation of novel innovations. One focus of the use of ET should be health equity versus health disparity. Given the differences in health status globally, populations should be represented and targeted in the life cycle of ET implementation. This divide exists, as evident in the different ways in which people live in their environment—which is difficult to collect in clinical systems (Correa-de-Araujo, 2017) and present clinically—access healthcare, and receive treatment. In the development of ET, another gap exists, in the people represented in data sets at the center of ET development and receiving its benefits. Data that represent and affect people’s lives derived from the non-medical drivers of a patient’s health can improve quality of care and enrich the utility of so-called intelligent machines (Ready, 2017), such as those used for machine-driven ETs in healthcare. Much of what happens in people’s health, which lies outside of clinician and administrative data collection from electronic health records (EHRs) and administrative claims data, is critical to collect, analyze, and be represented in the data that feed ET. Because of this, the likelihood of health disparities increases in the use, access of, and deriving benefit of emerging technologies. This is the reason the precise representative of all populations in health IT systems is imperative.
The SDoH are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. They are the conditions in which people are born, grow, live, work, and age—the circumstances determined by the distribution of money, power, and resources at global, national, and local levels (World Health Organization, 2018). Additional conditions, such as where people learn, play, and worship, affect a wide range of health, functioning, and quality-of-life outcomes and risks. The patterns of social engagement and a sense of security and well-being affected by where people live (Centers for Disease Control and Prevention, 2018) give us a better understanding of health status. Because of the difficulty in collecting these social and environmental factors in the form of data, a greater divide exists to portray the finite characteristics of all populations in healthcare accurately.
Data and Health Equity
The use of Big Data and data science methods to advance the field of symptoms management is in its infancy (Correa-de-Araujo, 2017). Related to the development of technology is the greater recognition of what’s involved in getting and keeping people healthy, rather than what happens in the clinical system (Ready, 2017). The exclusion of age, gender, race, sexual orientation, and culture in accurately determining a patient’s health status presents a risk of misrepresenting access and inclusion in data sets and therefore skews the outcomes, inclusion, and accessibility to healthcare services and treatments at the population level and point of care.
For clinicians, health disparities and exclusion of specific populations from accessing ETs cannot be paused for future ethicists to address. Health IT researchers, such as those studying AI, are now presenting their healthcare technologies as viable for providing both second opinions and alternative options in care delivery (Gershgorn, 2018). This fact makes it imperative to ensure policies and regulations are in place to include all populations equally in the development and testing phases of ETs, contrary to the reality today.
NURSES: CATALYSTS IN EMERGING TECHNOLOGY DEVELOPMENT
Serving the Quadruple Aim is the goal of using ETs. To bear fruit, nurses must be a part of creating novel scientific machinery, by inventing new products and services, and also influencing the design and use of new care models. Historically, nurse practice was based on standardization of care based on policies, procedures, and protocols, which led to limited opportunities for innovation. Today, a chance to transform practice lies in using ETs to better care for patients, decrease healthcare costs, and enhance patient experience and engagement while improving clinician well-being to disrupt the healthcare industry.
A Call to Action for Nurse Innovation
There has been a summons for nurses to be partners within their health organizations to advance healthcare innovation. In the 2010 Institute of Medicine’s (IOM’s) landmark report The Future of Nursing, Leading Change, Advancing Health, national healthcare leaders and policy makers put forth specific guidance for nurses to further the profession through the recommendation of evolving education standards, workforce designs, practice models, and the use of health IT. The specific proposal for promoting the conception, development, adoption, and effective utilization of innovative technologies is to “expand opportunities for nurses to lead and diffuse collaborative improvement efforts” (IOM, 2010, p. 11). Further, the report asserts that this should occur through healthcare organizations engaging nurses to collaborate with health IT developers and manufacturers in the design, development, purchase, implementation, and evaluation of medical devices and products (IOM, 2010, p. 11), and that “These entities should also provide opportunities for nurses to diffuse successful practices” (p. 11). Regarding innovation and new care models, the report stresses a necessary industry-wide action is “changing the way we think”—discarding our current models of work and replacing them with something altogether different—and health organization leaders need to foster cultures of innovation and build effective teams to do their jobs, requiring drastic culture change and transformational leadership (p. 417; Case Study 1.2).
CASE STUDY 1.2
A LEADER’S ROADMAP TO NURSE-LED INNOVATION
A conversation is beginning about nursing innovations as it connects to the future of clinical practice. We are in the infancy of nurse innovation and are beginning to understand what it is, how to harness it, and how nurse leaders must respond to involve nursing in understanding and to operationalize innovation concepts to nurses in clinical settings for the dissemination of evidence-based practice (Davidson, Weberg, Porter-O’Grady, & Malloch, 2017). The advancement of prioritizing innovation strategy for implementation of disruption in healthcare organizations is trickle-down. Nursing leaders across the care continuum require comprehension of innovation concepts to further great ideas from nurses that enhance patient care delivery, whether it is encouraging nurses to the development of new devices, methods to improve clinical and administrative workflows, or evidence-based practice frameworks. Nurses on the frontlines of patient care must be free to create novel products, processes, and models, and a robust leadership paradigm that is well versed and committed to an innovative spirit will do so (Davidson et al., 2017).
To advance innovative change, nurse leaders must understand what differentiates innovative healthcare organizations from others and puts them ahead of the curve in transforming care, in forward-thinking nursing environments—clinical and nonclinical professional—advancing innovation. Nursing leaders’ guidance and enablement for all nurses to be disruptive encourages and furthers nurses’ innovation knowledge, beyond the bedside and into shared-governance committees and risk management and quality improvement teams that will own and guide transformation in care through team interaction that stimulates the innovation process. Nurse leaders can create settings to learn about and adopt innovation concepts and institute them appropriately where care is planned, taught, and delivered by nurses who develop policies and procedures, as well as project, manage, and engage in operational excellence. These departments are many times nurse-led—they are the teams in a healthcare organization that identify issues in care, understand change management, and can sustain new practices that result from innovation projects (Carroll, n.d.).
An actionable, beneficial nurse innovation leadership guide published in 2016, The Innovation Road Map: A Guide for Nurse Leaders by Cianelli, Clipper, Freeman, Goldstein, and Wyatt, lends nurse leaders a deep dive into the components, characteristics, and collaboration needed in high-functioning innovative healthcare organizations focused on nurse-led innovation, and how leaders encourage the use of innovative concepts in evidence-based practice.
| Leading Nurses in Innovative Healthcare Organizations |
|---|
| Characteristics | Divergent thinking | Leaders encourage different vs. linear thinking, and the behaviors consisting of trying something completely new and different from current practices, in a safe environment for nurseswhere leaders view failure as opportunities for learning.
Leaders enable nurses’ ability to adapt quickly to rapidly developing trends and changing market conditions, and act based on their knowledge and judgment, within their full scope of practice as defined by existing professional, regulatory, and organizational rules. |
| Risk-taking |
| Failure tolerance |
| Agility and flexibility |
| Autonomy and freedom |
| Components | Employee feedback | Leaders promote the impetus for change by allowing nurses’ input, both positive and negative, to develop ideas for transformation, and hire courageous nurses and executive leaders with keen imagination and vision, who mentor and provide recognition to stimulate creativity and challenge the status quo.
Leaders identify and safeguard engagement activities and committees that spark and feed nurses’ creative spirits and identify early adopters and champions for transformation, to enlist help to encourage widespread innovative approaches such as teaching design thinking and concepts of invention to solve standard nursing problems.
Leaders provide nurses with exclusive technology resources that allow for idea-to-concept discovery through access to scholarly literature databases and hands-on learning-labs and advocate for the use of transformation methodologies focused on observation, ideation, rapid prototyping, user feedback, iteration, and implementation, keeping the end user in mind while creating and applying innovations.
Leaders, at all levels in the organization, are visible, vocal, and active role models for nurse inventiveness, and control innovation expenses that, while not producing a financial return on investment, have a lasting cultural impact for positive change in the work environment. |
| Role filling |
| Role modeling |
| Employee engagement |
| Education |
| Protected time |
| Technological support |
| Rewards |
| IDEO methodology |
| Budgeting |
| Leadership |
| Collaboration | Unlikely and diverse team members | Leaders support nursing team collaboration by including enthusiastic and risk-tolerant, uncertain, and varying members committed to a common goal to encourage productive interaction, taking into account all perspectives and backgrounds to see a project to completion.
Leaders promote a fun atmosphere to stimulate creativity and allow rest during innovative work sessions, developing nurses’ aptitude for novel thinking to make the collaborative process more inventive and efficient. |
| Productive interaction |
| Play pauses and breaks |
| Skill set development |
The Power to Transform Care
Nurses are highly skilled and well-trained innovators, who can lead the revolution to transform care through the use of ETs. With a keen ability to create new ways to deliver safer, quality care, improve health outcomes, and enhance patient experience through the acquisition of technology and strategizing its use, nurses are well positioned to be the pioneers of new ways to ignite change and continue to be the foundation of organizational stability and growth (McGonigle & Mastrian, 2017, p. 111). For care delivery to indeed evolve, nurses as knowledge workers must disrupt practice patterns that diminish useful results and embrace a collective goal to improve care through process redesign and use of IT and advanced analytics (HIMSS, 2011). Clinical practice transformation moves “beyond the form and function of nursing practice as we know it today by boldly advancing the redesign of clinical processes and being open to emergi1ng transformative possibilities within society and healthcare through the use of technology” (Nagle & Yetman, 2009, p. 2).
Clinical transformation involves assessing and continually improving patient care delivery at all levels in healthcare. It occurs when existing inefficient or less effective care models are rejected, and a group or organization embraces a common goal of patient safety, clinical outcomes, and quality care through process redesign and technology. By expertly blending people, processes, and technology, clinical transformation occurs across facilities, departments, and clinical fields of expertise (HIMSS, 2011). With this in mind, clinical practice transformation, led by nurse knowledge workers, is possible with the adoption and use of ETs, such as AI, VR, and the IoT. Nurses have an immense opportunity to guide their application in evidence-based practice for multiple use cases. Combining ET with significant clinical knowledge, and through understanding and implementing innovation skills, nurses have the pull to bring this to fruition and add value to clinical practice by leveraging it (Case Study 1.3).
CASE STUDY 1.3
PUTTING IT ALL TOGETHER HELPSY HEALTH: A VISIONARY NURSE-LED START-UP FOR CANCER SYMPTOM MANAGEMENT AND REFERRAL
Across all industries, new companies are exploding on the scene at a rapid pace to develop new services, products, and processes designed to disrupt current business models and leverage technology to challenge the status quo. Healthcare start-ups are no exception. Clinician-led companies are identifying patient-centered direct care and administrative payment problems and are quickly developing innovative health IT solutions to fix them. With a focus on care quality, patient experience, engagement and satisfaction, and reducing healthcare costs, hundreds of companies have set out to meet the dimensions of the Quadruple Aim—the modern framework designed to improve healthcare delivery.
Helpsy Health, a Silicon Valley-based, nurse-led healthcare start-up, had developed an artificial intelligence-based solution explicitly focused on improving patient care quality and safety and reducing medical costs. The company’s comprehensive symptom management software platform for cancer patients was established in 2016 to meet the need for vital support for patients experiencing physical and emotional cancer symptoms that busy providers cannot. The company’s vision of the future is one where cancer patients, experts, and treatment centers are able to benefit from and provide high-touch care quality and increase care team efficiencies. Their aim is to leverage technology to enable patients to better engage and make their care choices and have better, more timely access to cancer experts and resources. Their patient-centered software platform is designed to significantly reduce these barriers to care and financial concerns through ongoing support from nurses and interprofessional care teams, thoughtful use of technology for easier connectivity to provide continuity of care, education, and reminders, where healthcare organizations are limited financially.
In its inception, Helpsy Health identified evidence-based critical quality, safety, and financial issues related to cancer care. The company found that 90% of patients with complex conditions such as cancer experience preventable adverse events due to lack of patient education, continuity of care, and treatment adherence, with each event costing approximately $20,000 per patient per event; 77% of this cost is passed onto insurance companies and self-insured employers, resulting in high costs to all (S. Agarawal, personal communication, June 9, 2019). As hospitals and cancer centers aim to provide critical, continuous follow-up care, cancer patients need to manage side effects and continuing symptoms; with the 2015 Commission on Cancer mandating cancer centers provide survivorship care, cancer providers continue to lose over $50,000 per year to maintain comprehensive care programs (S. Agarawal, personal communication, June 9, 2019). Because insurance companies cover 1 hour for care planning per patient visit, cancer care management can be arduous and expensive, and barriers remain to successful survivorship programs that are detrimental to cancer survivors’ lives.
Armed with this knowledge, Helpsy Health has set out on a mission to create a futuristic care delivery and payment model to help patients, care delivery teams, and cancer centers use technology to bridge care gaps and improve efficiencies by offering critical symptom-focused, personalized patient care plans. Their innovative, customizable, and HIPAA-compliant platform supports cancer patients in searching for options based upon their condition and individual needs and in collaboration with healthcare teams, and ensures effective results (Agarawal, 2018). Their novel solution offers a comprehensive, whole-health symptom management and navigation platform that addresses cancer patients’ physical, emotional, and social needs to create a whole-healthcare plan for patient symptoms, utilizing 20,000 recommendations and 5,000 resources across 20 social determinant categories, in real time (Helpsy Health, 2019a).
The Helpsy Health software platform offers a patient a portal in addition to a smart device app that connects to virtual services to access and develop symptom management and Quality-of-Life Care Plans (Helpsy Health, 2019b). The care plan includes treatment education, symptom management, medication adherence monitoring, and reminders, and provides community resources to improve care coordination during and after cancer treatments. At the core of the cancer care plans is the combination of evidence-based therapies from multiple modalities including nursing, social work, nutrition, and mindfulness following guidelines proposed by the NCCN, ONS, the ASCO, and other professional organizations. Ongoing symptom and adverse event management platforms remind patients of upcoming visits and testing, direct patients to in-network services, and provide continuous active and passive monitoring through wearables and EHRs. For interprofessional care teams, the online cloud-based, EHR-integrated solution enables efficient checking and adjustments of the patients’ care plans throughout successive treatment phases to promote patient care team connectedness and improve patient engagement. The platform also risk-stratifies cancer patients using clinical decision support to alert care teams of high-risk patients and patient decline, supporting actionable, efficient, precision care, and decision-making. Platform analytics provide insights for quality, performance, and cost metrics, and collect patient satisfaction scores and once manual cancer screening tools such as the PRO, Distress, and RWE virtually (Helpsy Health, 2019b).
Early studies of their platform in collaboration with the National Institutes of Health and the University of California San Francisco (UCSF) provided evidence of the need for a cancer symptom management solution. An unmet need supported cancer care teams to complete higher value tasks and improve patient experience and empower cancer patients and their care partners to have continuous clarity, guidance, support, and assistance between provider visits. As demonstrated in clinical studies of the Helpsy Health solution (S. Agarawal, personal communication, June 9, 2019), patients using the intelligent symptom management platform and referral service improved by 30% to 70% and quality of life improved by 14% to 78%. When investigating cost savings models, Helpsy Health’s solution saved insurance companies $5,000 per patient during active treatment. For value-based care organizations, conserving resources and minimizing costs enabled health providers to implement high-quality care through provider referrals to the patient-centered service (S. Agarawal, personal communication, June 9, 2019).
Helpsy Health’s desire to facilitate the emergence of a new healthcare ecosystem by connecting experts, patients, and centers using its intelligent, online, customizable, comprehensive survivorship care program that cancer patients have been struggling to find, and cancer centers have been struggling to provide, continues to grow in the marketplace. Nurse-led innovations and start-ups such as Helpsy Health empower nurses to develop and use novel technologies to transform care through software platforms to guide patients, care partners, and care teams virtually, with health IT devices, products, and services critical to modern healthcare delivery in ambulatory and virtual settings. Health IT start-ups, such as Helpsy Health, are changing how nurses provide care using emerging technologies to improve complex patient care and move the healthcare industry further to meet the Quadruple Aim.
