Cutting across the sessions at the Million Hearts™ event were considerations around the many factors that can affect the spread of cardiovascular innovations across various health care settings. The broad environment needs to be made receptive to the need and possibilities for improvements in care. How can “fertile soil” be cultivated for the successful spread of new practices in cardiovascular care? Successful spread requires each health care organization to decide to adopt and implement these innovations. What factors affect whether initial interest translates into adoption and sustainable implementation of these new practices? What roles are critical during the early stages of implementing the innovation? And what tactical issues might be considered in designing efforts to embed novel practices within existing organizational structures?
Creating Receptivity to the Spread of Cardiovascular Innovations
Integrating Million Hearts™ Goals into Ongoing Initiatives
To create “fertile soil” for the spread of cardiovascular innovations, meeting participants emphasized the need for Federal government agencies to support the goals of Million Hearts™ within other programs, funding opportunities, and portfolios rather than pursuing the Million Hearts™ initiative as a completely separate endeavor. They suggested that integrative efforts across the Federal sector will allow the private sector to respond in a more coordinated and efficient manner to the Million Hearts™ initiative. To illustrate this point, one audience member remarked, “[Organizations] have funds that come from meaningful use. They have funds that come from Patient-Centered Medical Homes. They have different requirements for both … They don’t have the flexibility in the funding that allows them to fill gaps and cross utilize.” Other related recommendations were to integrate the Million Hearts™ initiative into the work of the Center for Medicare and Medicaid Innovation (CMMI). An example of how this could be done was to ensure that the “ABCS” are included or measured as part of the CMS initiatives (e.g., pioneer Accountable Care Organization [ACO] model, shared savings initiatives, or the comprehensive primary care model).
Incorporating heart-healthy activities that reflect the aims of Million Hearts™ into daily culture was another variation of the full integration idea—“from what food we offer in cafeterias and vending machines, to the policies that we’re setting, and to the things that we are measuring,” as articulated by one participant. Though it was suggested that all organizations strive for this type of integration, meeting participants singled out the public sector, as a large employer, as being well positioned to serve as a role model. One audience member reminded, “We keep forgetting the Federal and State governments are huge employers. We should start talking about government as employers,” and another noted, “An important part of the conversation is getting the public sector to act as an employer and do it themselves … ‘walk the walk’” and set an example.
Using Media to Promote Stories of Change
“[Use] not just the print media but the broadcast media and get the stories out because so many of these innovations, if they could be brought into telenovela or into other things that demonstrate to consumers, to patients what’s going on, that would promote change.”
Robert Like, Robert Wood Johnson Medical School
Media can be used to help health care innovations “go viral.” Media can be used to expose providers and patients to innovations in an engaging and comprehensible manner, possibly inspiring providers to consider implementing innovative programs in their health care settings and creating patient demand for similar types of health care services. Many channels of media are now available to bring attention to successful innovations, including traditional media (e.g., daily newspapers or nightly television news), and new media (e.g., online blogs, Twitter, or LinkedIn Groups). Successful exposure is created by combining the use of media to reach target audiences in multiple ways. Regardless of which media are used, bringing successful innovations to the attention of those at the “sharp end”—patients, providers, health care staff—can help to create demand for innovation.
The Asheville Medication Therapy Management innovation provides one example of the value of media exposure. This innovation was featured on NBC Nightly News (http://www.youtube.com/watch?v=IoASKNZ4rM8) and was later spread in many parts of the country.
Thomas Frieden, Director of the CDC, threw out the challenge of “Everywhere, Now!” when he addressed the participants at the event. An innovation that is successful in improving people’s health needs to be everywhere immediately. In his opinion, lack of a sense of urgency is the most frequent cause of failed change efforts. Urgency can be generated by using the media to make people aware of the importance and possibility of change.
Dr. Frieden’s sentiment was carried throughout the day, and its value was demonstrated during the interactive 3x5 activity concluding the day. Asked to select the best ideas that emerged from the day’s discussions, participants identified two media-related ideas as among the most important—the need to “involve other media outlets to share the stories of innovators in the Million Hearts™ campaign” and the need to “get more press on the successful innovations.” Action on these ideas has the potential to create the “everywhere now” urgency that was called for by Dr. Frieden.
Combining Stories and Data to Motivate Change
Evidence about the effectiveness of an innovation often takes the form of quantitative data, covering a variety of areas such as clinical outcomes, process or activities, cost, value, and efficiency. Quantitative data illuminate the need for improvement within health care organizations and larger communities, and help document the improvements resulting from implementing innovations. Dr. Frieden emphasized the role of solid real-time data to support quality improvement. “One of the things that holds us back is an inability to see what the data are showing in real-time … Focused-in information systems are critical to overcoming the barriers to quality improvement.”
However, numbers alone may not be sufficient to catalyze change. The Million Hearts™ event emphasized the importance of patient stories as a powerful complement to quantitative evidence about an innovation’s impact. Patient stories create the personal connection that can serve as a motivator for change. Barry Bunting stated, “What really gets [adopters], and what really flips the lever to activate them to making this something that they become at least modestly passionate about is the personal connection of why this matters to them.” MaryAnne Elma, American College of Cardiology, seconded this sentiment: “To make it meaningful, you have to connect it to what people are really feeling and dealing with.” Patient stories can go a long way to connecting potential adopters with why an innovation is necessary and what it means to those in their community.
Creating Organizational Readiness to Adopt Innovations
Openness to Change
A key reference to see if your organization has the ability to adopt an innovation is the AHRQ Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations, available at https://innovations.ahrq.gov/sites/default/files/guides/InnovationAdoptionGuide.pdf.
Organizational culture was repeatedly discussed as an important foundation for successful implementation of innovations. How receptive is a given setting to a new idea or intervention? Million Hearts™ participants underscored the importance of organizational patterns of behavior that rewarded proactive interest in continuous learning about new ways to improve care. Such proactive learning cultures are not yet the norm in most health care organizations. As Barry Bunting of American Health Care pointed out, “People are so stuck in what they’re doing that they’re not aware of the innovations that are out there. So they need to know that the change is possible.”
However, openness to change can be embedded into an organization’s way of operating. René Vega, Aetna, discussed how his organization’s culture of innovation is demonstrated in a systematic, three-step process used to develop, evaluate, and integrate innovations into the routine work of the organization. “Aetna’s three-step approach [is] research, pilot, and integration of the enterprise.” In this process, Aetna first researches elements of a potential innovation to be operationalized, implements a pilot study to identify which elements are successful, and combines these successful elements into an enterprise-wide initiative.
Every organization has competing priorities for its finite focus, time, and resources. Often, timing is a critical factor for an innovation’s adoption and spread—innovations have to be viewed as a solution to a problem that the organization currently views as a priority. Changing priorities may affect the fate of an innovation. David Magid, Kaiser Permanente Colorado, discussed how his organization’s priorities shifted over time. Organizational priorities aligned with the Heart360® innovation when it started—blood pressure was seen as a high priority problem. However, general improvements in blood pressure readings among the Kaiser Permanente population over time contributed to lower priority on blood pressure, and along with it, support for the innovation diminished in his organization. He said, “We are [now] very much at the top [in blood pressure control], and so it’s not quite the priority that it was when we started the project. And in an organization of our size which is a little more than half a million people, we have limited bandwidth to do big projects … [and this project] requires a lot of resources and energy to do, and with a number of other priorities that we have, it’s just not on the list at the top.” Because of this decline in organizational support, the program could not muster the attention and resources necessary to expand throughout the Kaiser Permanente Colorado system.
Innovation Champions and Obstacles
“There’s a difference between kind of being generally supportive and sort of getting on your horse with your sword in your hand and marching into battle.”
David Magid, Kaiser Permanente Colorado
The importance of a champion is a truism in the literature on the diffusion and adoption of innovations. Not only must there be a champion ready to “march into battle,” as David Magid colorfully stated in his description of conditions that were needed to spread the Heart360® innovation, but there must be continuity in the champion role. René Vega, Aetna, seconded David Magid’s point on champions. He stated, “You need to have a dedicated champion, a committed individual. Hopefully, one that will be there through the entire course of the program.” Champions connect with leadership, keep the health care team motivated, and overall, they help sustain the innovation.
Comparisons of the conditions surrounding the implementation of the Heart360® innovation in the Kaiser Permanente systems in Colorado and Southern California underscored this point. When the initial champion left Kaiser Permanente Colorado, support for the program diminished, leading to a cessation of spread within the Colorado system. In contrast, implementation of the Heart360® innovation in Southern California Kaiser has been successful because of the presence of a strong champion. “Joe Handler … who runs the hypertension program in Kaiser Southern California … is definitely one of those guys on the horse with the sword … He has brought together the sponsorship he needs to try and move this quickly, and they’re already starting a pilot with over 600,000 patients.”
The role of the champion was also emphasized by Barry Bunting in discussing the spread of the Asheville Medication Therapy Management innovation. While this innovation has spread to many communities, “There have been some attempts to do it where it hasn’t worked. Part of that may be due to … the need for a champion … for individuals in that community to actually step up to the plate.”
Champions are critical to “march into battle” in order to address the many organizational barriers that stand in the way of implementing innovations. By their very nature, health care innovations disrupt the traditional ways of working in an organization, and it is often difficult to synchronize all parts of the organization that need to make these changes. This coordination, or lack thereof, is critical to the uptake of programs. René Vega touched on Aetna’s challenges with organizational coordination during his presentation. He stated that the adoption of his blood pressure innovation, even in an organization like Aetna, which has a built-in process for coordination challenges, can hinder the uptake of innovations. “You still need to work within the population and the various departments within your organization—medical services, member services, sales, and the like—so that they can coordinate their activities. It is really imperative that there be cross functional integration among the units. Of course, the bigger the organization, and the more complex it is, the more difficult it’s going to be as opposed to a ten-physician, one-site clinic.” Coordination is difficult because many different facets in the organization need to work together in order for the innovation to be successful. Resistance by any one of these areas may block efforts to change the status quo.
The challenge of organizational coordination is not the only organizational barrier to innovation. Many times key individuals may have their own reasons to be critical of new programs. The Million Hearts™ event participants debated when and how to engage the naysayers. One perspective offered was that it was essential to engage naysayers in initial talks about program adoption—if the naysayers are absent from the early discussions, one will not know how the program can be sabotaged at a later point. On the other hand, early objections can derail a program before it can gain momentum. A compromise position was offered by Judy Hannan from the CDC: “I think one of the things about … inertia and naysayers is you have to engage them early and separate from the group … You have to build their trust, build their confidence if [you’re] going to be listened to, and you have to engage them offline first.” Sometimes the loudest of naysayers, once convinced, will become the greatest of champions.
Throughout the day, participants in the Million Hearts™ event discussed several tactical issues that adopting organizations would need to consider in working out the implementation tactics for embedding the innovation into the organization’s daily routines.
Incremental vs. Radical Change
There was much debate at the event whether to approach innovative efforts incrementally or aim for more comprehensive programs at the outset. Bruce Coles, New York State Department of Health, brought up this point during the Aetna fishbowl. New York has a “lot of different programs across the state who are doing quality improvement projects, and we get two opinions—one says you’ve got to work with low hanging fruit on one single thing because at the practice level it’s very difficult to implement standards for a variety of different projects if you want to get things moving and up to scale. On the other hand, others have taken the track of [taking on] multiple [conditions] but they are multiple years into their project before they even have their patient portals ready to start telling the story, so both have their drawbacks.” Mr. Coles got right to the heart of the debate: Do you implement solutions incrementally, addressing easier problems first in order to achieve early success and build trust and momentum before incrementally scaling up? Or, do you aim to create a more comprehensive program that may delay implementation and demonstration of success?
For many reasons, change often happens incrementally in practice. Radical change can be seen as too risky, and health care organizations tend to be risk averse. Stepwise implementation is easier to start, and this approach makes changes easier to assimilate, particularly for complex innovations. Drawing from an extensive literature in managing organizational change, Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations,11 suggests the use of small-scale trials, limited in time or scope, and phased in over time. Aetna is a good example of an organization that does precisely this. As noted above, they have a vetted three-step approach: research, pilot, and finally integration of the innovation into the enterprise’s routines.
Narrow Focus, Stand-Alone vs. Integrated Solutions
Mark Smith, MedStar Health, brought up a similar point in considering the Medication Therapy Management innovation. He questioned the usefulness of building stand-alone solutions for particular conditions, such as controlling blood pressure or cholesterol levels. He said, “I’m always worried about building stuff on a one-off basis in solving a one-off problem … as opposed to building an extensible, fungible infrastructure that could be pointed to solve many problems … in other clinical domains.” His statement gets at an important issue for any narrowly focused clinical innovation. For people with multiple conditions, focused innovations may reinforce a fragmented approach to delivering care, which may be inconvenient, inefficient, as well as potentially ineffective.
Barry Bunting, American Health Care, agreed on the importance of treating the “whole person,” not just one medical condition. “What we realized, even though our initial program was targeting diabetes, is you get the whole person … They’re in a diabetes program, but they also have migraines, they have prostate issues, they have Raynaud’s, you get the whole thing.” Bunting continued on to say that a pharmacist cannot look only at a patient’s diabetes medicines; instead pharmacists will look at the patient as a whole and consider the migraines, the prostate issues, and other conditions, in addition to the diabetes. One approach to this problem, coordinating a particular innovation with other treatments, was suggested by René Vega, when he discussed his experience with Aetna’s Disease Management program. “About a third [of all patients] may in fact either be hypertensive or pre-hypertensive. Anything you can do in collaboration with other groups is going to … make [the hypertension innovation] more successful.”
David Magid, Kaiser Permanente Colorado, noted that the decision to design a stand-alone innovation or a more comprehensive approach may depend on the innovator’s goals.
He said, “If you are testing out a new technology [such as the blood pressure cuff in the Heart360® innovation], it may make sense to initially test that out in a specific group like we did with hypertension. On the other hand, if you’re trying to improve cardiovascular health, then you really want to take a broader approach, and you want to be addressing hyperlipidemia, smoking, exercise, and so forth.”
Using Technology to Support Implementation
In an era of rapidly changing technology, adopting organizations may consider modifying the technological infrastructure used in implementing cardiovascular innovations. In the discussion of Magid’s Heart360® innovation, participants noted how the use of alternative technology can help ease the implementation burden. Although patients in Magid’s innovation were required to use computers with Internet access, he pointed out that this may not be the preferred mode of transmission in other settings. Using another form of technology, such as smart phones, could make this program accessible to more patients. A system using Bluetooth or another transmission technology would allow data transfer over a cellular phone instead of requiring a computer and Internet access. Herbert Smitherman, Wayne State University and Health Centers Detroit Foundation, Inc., agreed that in his community, using cellular phone technology would be more effective for his low-income patient population. As noted, this demonstrates how no two health care organizations are alike, so it is necessary for an adopter to think about how technology can apply in his or her setting to ease the implementation burden.
Technology can also be employed to ease the burden for the affected providers. Barry Bunting utilized technology to ease the provider burden and enhance the Asheville Medication Therapy Management innovation. Three to four years into the program, he recommended that the pharmacists begin to document visit notes in an EMR. “It just isn’t going to work if it takes them longer to document their visit than it did to see the patient,” Bunting stated. The biggest positive evolution in the Asheville program was the efficiency gained from shifting paper-based documentation to the EMR.
11 Will it Work Here? A Decisionmaker’s Guide to Adopting Innovations.https://innovations.ahrq.gov/sites/default/files/guides/InnovationAdoptionGuide.pdf.