Thursday, February 23, 2006

Trauma Centers and the Need for Disruptive Innovation

Seeing What's Next

Recently I read Clayton M. Christensen's new book, "Seeing What's Next: Using the Theories of Innovation to Predict Industry Change", and found myself feeling more invigorated at the thought of participating in the transformation of our Healthcare System. The position I have taken in this blog is that what we are experiencing as a Healthcare crisis is really the transformation of an established paradigm for delivering healthcare into a new emerging paradigm for delivering healthcare. Chapter eight of "Seeing What's Next", titled "Healing the 800-Pound Gorilla: The Future of Healthcare", indirectly suggests this hypothesis and specifically outlines how it not only can happen but in all probability is happening. Christensen's "disruptive innovation theory" demonstrates how "new organizations can use relatively simple, convenient, low-cost innovations to create growth and triumph over powerful incumbents." The underlying assumption is that healthcare is an industry and like all industries is subject to the forces that influence the market in which it thrives. If so, then how could it influence the field within which I trained, Trauma and Surgical Critical Care?

Is the Field of Trauma Really in the Gunsights of Disruptive Innovation ?

Trauma is a field that is ripe for innovation based on one simple observation. A large proportion of the patient population served is what Christensen would describe as "overshot customers". This is a patient population (particular customer segment) for which existing services are "more than good enough". You may ask, How can I make this claim? I base it off the observation that the majority of patients treated at Trauma Centers and registered in the National Trauma Database (NTDB) have minor injuries. Over two-thirds (68.4%) of the patients in the NTDB were found to have an injury severity score consistent with a minor injury and yet all of them were evaluated by a Trauma Center. Nearly half (49.1%) of all patients with minor injury severity scores were treated at Level I Trauma Centers which are the most resource intensive hospitals in the country. So why do almost half of the least injured patients in the United States end up at centers which are the most expensive providers of healthcare services? Like many things in life, it's complicated.

Is it Possible to be Too Good?

Trauma Centers, especially Level 1 Trauma Centers are victims of their own success. To maintain a "Level 1" status a trauma center must commit to a very high level of resources, not the least of which is human resources. Patients who meet specific anatomic (gun-shot wound to the chest), physiologic (low blood pressure from blood loss) or mechanistic (rollover motor-vehicle accident) will be triaged to a trauma center. Trauma centers have the resources and expertise needed to treat the most severely injured patients on a 24/7 basis. As they became proficient at what they did they attracted more patients. Trauma patients usually don't choose where they go so this is done by the EMT's or Paramedics transporting the patient. Since they prefer not to undertriage (send a patient with a serious injury to a non-trauma center) they tend to overtriage (send a patient with minor injury to a Level 1 Trauma Center). The Trauma Centers are loathe to discourage business so the cycle continues to progress and the total trauma patient population is "overshot". In most Trauma Centers Trauma Surgeons are the leaders of the teams activated to evaluate these patients. What this means is that a Surgeon who spends most of their professional career mastering the art of Surgery ends up taking care of patients who don't need a Surgeon to care for them. How does this happen? I've commented on this in a previous post but it is worth repeating.

"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)

There is actually another reason and in the parlance of the business world, the Trauma Centers have become the "incumbents" of the trauma market. There once was a day not so long ago when the high end care provided by modern day Trauma Centers was not available. It took the vision, dedication, hard work and commitment of individuals such as Dr. R Adams Cowley to introduce the "disruptive innovation" of Trauma Centers and move it into the mainstream. Trauma Centers have gone from being rare and the exception to the common and the exceptional. As with all growth industries Trauma Centers have matured and in doing so have "overshot" their customers. While this may introduce an element of waste it also exposes the industry to opportunity for innovation. Overshot customers create potential opportunities for "Low-end disruptive innovation". This is an "innovation that offers overshot customers good-enough performance along traditional metrics at lower prices".

Innovation Lessons from Healthcare

In "Seeing What's Next", Christensen et al, point out there are three general lessons to be learned regarding innovation in healthcare which are:
"1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Nonmarket forces affect the market for innovation by influencing industry players motivation and ability."
So how does this apply to the overshot customers within a trauma patient population?

"Bad laws are the worst form of tyranny."
Edmund Burke (1729-1797)

Trauma Centers are very good at categorizing patients and providing timely treatment. Most of the rules, that is protocols, for guiding treatment have focused on the more severely injured patients as their injuries are the most life-threatening. Minor injuries were relatively easy to treat and did not warrant the time and energy to develop specific rules for treatment. This is particularly true at the major Trauma Centers. Protocols were reserved for the common injury and disease patterns seen in the more severely injured patients. That is, after all, the specific patient population for which Trauma Centers were designed. Based on disruptive innovation theory I predict that the development of protocols that specifically address the needs of those patients who have minor injuries and are being treated at Trauma Centers will be one of the first steps in the direction of a low-end disruptive innovation in the field of trauma. The key to these protocols will be to incorporate them into a quality improvement program that is designed to continually improve the care of the patients for whom they were developed, because without this they are no better than "bad laws".

Now the Difficult Part to Accept

With a set of rules to guide medical decison making in the treatment of patients with minor injuries this allows the next step to occur. This is a "provider-level disruption" where less-skilled providers such as Nurse Practitioners (NP's) or Physician Assistants (PA's) provide care which does not require the judgment and skill of higher-skilled providers such as Trauma Surgeons or Emergency Medicine Physicians. This also allows the movement of treatment to areas that are more convenient and less costly for the patient. Free-standing "Minor Trauma Centers" are unlikely due to the restrictions on specialty hospitals and the fact that they would share the same "value network". A more likely scenario is for the "Incumbent" Trauma Centers to internally develop "Minor Trauma Center" sub-specialty areas on the same physical site as the major Trauma Center. While this is already happening to some degree at very busy trauma centers out of necessity it is not the norm at most centers. So if two-thirds of a Trauma Surgeons patients are being evaluated downstream by NP's and PA's then what is the Trauma Surgeon going to do?

Move upstream

The Trauma Surgeon will do what any service provider does in a mature market. They will need to go upstream. Most facilities already utilize the Trauma Surgeons skills to cover Urgent and Emergent General Surgery so this is not a new market. There has been a great deal of discussion among Trauma Surgeons and the current view is that they should become Acute Care Surgeons. In case anyone in the medical community hasn't noticed we already are Acute Care Surgeons. I think we need a more radical "sustaining innovation". Moving upstream means acquiring new skills to meet the demands of the market in which they most commonly practice. If Trauma Centers in the United States continue to see shortages of Neurosurgeons, Orthopedic Surgeons and Plastic Surgeons then it is up to the Trauma Surgeons to develop the skill sets and the training programs necessary to provide those services. As those specialties move further upstream to ambulatory surgical centers, specialty hospitals and non-trauma centers they will leave behind them a void in the availability of essential services. As NP's and PA's move in from below and surgical specialists exit from above there will come a time when the Trauma Surgeon will need to step up and move as well. If we are going to do it then I suggest it is better to lead than follow. I don't think Dr. Cowley would mind.


Steve Beller, PhD said...


You’ve done an outstanding job exemplifying Christensen’s concept of “overshooting customers” with Trauma Centers!

As evidence-based practice guidelines/protocols enable more and more procedures to shift downstream to NP's and PA's, having Trauma Surgeons migrating upstream to fill voids in other subspecialty markets is an innovative idea.

A few questions: If you’ve discussed this concept with other Trauma Surgeons, what was their reaction? Do you see a similar thing ever happening in other specialties? If there is going to be an overabundance of physicians as recent research is indicating, might this "migration" process offer a partial solution?


Trauma One said...

Reactions among the few Trauma Surgeons I've spoken to so far have been mixed. Unfortunately most are against it. The reasons are complicated but I believe are best understood by what Christensen and Geoffrey Moore refer to as "Legacy Systems". Legacy systems are very good at sustaining innovation as long as it sustains the legacy. People who are very good at sustaining innovation are attracted to positions in legacy systems and are highly resistant to disruptive innovation (as I think you have encountered in the past).

I think this can and is happening with other specialties, especially Primary Care. Primary Care is at the leading edge and has so far taking the biggest hit. Examples include MinuteClinic and Medspot that utilize NP's and PA's for overshot customers.

I think all physicians will eventually face this to some degree. Moore calls this "Repurposing context for core" in his recent book, Dealing with Darwin. Physicians will need to constantly adapt and re-define themselves throughout their careers. I don't think building more or less medical schools is the answer to perceived excesses and shortages in healthcare.

Greg said...

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