BIOS Podcast #5: Healthcare Innovation & Implementation w/ Jessica Chao — Director @ UCSF Clinical Innovation Center

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Jessica Chao is Director of the Clinical Innovation Center @ UCSF, where she oversees operations and leads partnerships with industry and academia. She is an investor @ Iterative VC and has over 15 years of experience as an operator in health services and med tech management. Previously, she has led product design in various San Francisco startups and co-founded Healtho, a consumer health information company. She is also the co-founder of one of the largest health meetups in Seattle, the Seattle Health Innovators.

This article is a summary of key takeaways from the BIOS Podcast episode w/ Jessica Chao— Listen Here!

The Day to Day Role as Innovation Director

The USCF Clinical Innovation Center (CIC) was started six years ago to facilitate much-needed translation of the wealth of research at USCF into the health system. At its core, the CIC creates infrastructures to allow new technologies to be piloted and eventually implemented into health systems. The central goal of the center is to ensure operations work more efficiently, with day-to-day projects creating new services, partnering with industry to improve service, and changing the culture in order to facilitate the fluid on-boarding of new changes.

As the CIC director, Jessica speaks with numerous UCSF faculty to understand their pain points — and when creating a new service, professors speak with her to begin defining, developing, and deploying these services.

“It’s a double diamond model. Discovery is the beginning of the diamond where we go very broad to understand all the workflow, service, and all other financial and logistical inputs. Then, we define the state of what we want the service to be and then develop and deploy.”

Philosophically, the challenge is to get the whole health system innovative, not just the professors and entrepreneurs. On common issues that innovators run into when trying to implement projects,

“It’s really hard to come from a systems perspective….You can basically do a pilot and have it show [some] good result. But to be able to work with a system is something a lot of faculty don’t know how to do. [Starting from when] someone writes a paper…it’s basically a year-and-a-half long process.”

One example Jessica mentions is a test for nurses to administer in order to assess for symptoms of delirium. This seemingly small addition creates many more steps to account for in the care delivery system. Startups in particular commonly underestimate the complexity of implementation in a healthcare setting.

“In the beginning, when you tell a startup, “You actually don’t understand this, you have to learn about that,” it’s very hard for them to understand what they don’t know. Then maybe in Year 3 or 4 they come back and start to absorb what is going on. It’s hard [for startups] because there is a lot to digest at the same time…these are people with 10 or more years of experience trying to explain something to you.”

She notes that Ph.D.s and fellows who come in to learn about the workflow come back to her after three months often discouraged with the politics or bureaucracy going on. The key to addressing this problem is refining your product to a subset small and clear enough in order to truly solve the problem that was set out to be solved. In systems without an innovation center, this is a difficult problem to tackle independently. In such cases, Jessica suggests founders engage in robust product discovery interviewing. Don’t just interview doctors — speak to nurses, patients, and others to understand multiple perspectives and ensure that data points are being collected in a varied manner.

Driving Innovation in Health Systems

Health systems are notorious for being slow moving. On driving innovation in an organization with such inertia and resistance,

“I think talking to faculty and nurses, it’s clear that they want to innovate…I think that execution is probably where the sore point is for many organizations. Scaling past a pilot is where a lot of innovation fails. For example, if digital health teams want to scale to 100 clinics with many different scheduling templates, they will need an infrastructure in order for the implementation to work. It’s an implementation science problem.”

The risk of a technology is not necessarily the pilot or first few clinics, but rather scaling it into a large medical center or across multiple clinics. Academic centers are naturally innovative and research is ubiquitous across these institutions. However, care delivery innovation is not an area of expertise for most faculty, since their focus is on research, and not necessarily what is happening in the hospital setting. This disconnect means that part of the job for the CIC or any innovation center is an educational component, to train new implementation scientists.

Healthcare delivery innovation is fundamentally different from biopharma or biotech. With therapeutics, it is understood what the form factor for administration is and how it fits in the system — exactly the opposite for healthcare delivery services. From an investor point of view, evaluating ventures becomes a different game because risk lies at different points in a company.

“If I’m creating a pill, I just need to know that there’s a class — a condition that the FDA will approve….There’s a formulary, a pharmacy, and a distribution system. The EMR is built for these. Once [the pill is] on the formulary, you can just prescribe it — the entire ecosystem to support a pill is already built. The problem with an app is that it is so easy to build, but so hard to implement…You not only need to understand who is using it, but how is the system using it. So that automatically becomes much more complex.”

A specific example highlighting this difficulty surfaced recently due to the COVID-19 pandemic. Jessica is working with new digital solutions to help patients triage to correct clinical endpoints (e.g. an automated call goes out to all patients asking either to reschedule or transition to a video visit). However, Jessica realized that she would need to create a tech support team to teach patients how to use Zoom, which often requires up to half an hour per patient. This highlighted to Jessica that the barrier is not creating the triage algorithm, but rather ensuring its smooth implementation within the health system. All health systems serve a wide range of patients, including those who are less abled, unfamiliar with computer use, or multilingual. Reaching 100% of these patients is a unique requirement of healthcare solutions that adds to system complexity.

At the same time, the COVID-19 pandemic has given Jessica hope for the future:

“The hyper mode of us talking to each other and communicating: I love this because it’s problem solving…“Why did you come up with this, why is this solution working or not working?” I love all of those conversations….Allowing [conversations] to happen in days is amazing. Those conversations without COVID would have taken us months or years. Everyone is aligning their calendars for this issue, allowing people to talk to each other more and make decisions faster.”

Advice for Founders Working with Health Systems

Many founders hope to sell software or other solutions to medical centers like UCSF, and the first step is invariably a pilot. The two primary settings are generally at large academic research institutions like UCSF or smaller hospitals without the same name recognition, but still tech-enabled and capable of running a study. To this point, Jessica tells startups:

“Learn everything you can from health systems. They have this complex view with super insightful detail about the problem you want to solve. However, because it’s so complex, it is much easier to implement anywhere else. Faculty can help design a study and be useful in an advisory role as you do a study elsewhere.”

There is both a timeline and cost issue for working with large brand name medical systems. For instance, both the academic institution at UCSF and the health system at UCSF charge startups for access to professionals, services, and pilots. Adequately powered and well implemented studies can quickly become cost prohibitive to many small startups.

The tradeoff between a brand name hospital, which might open more doors in the future, versus ease of implementation, time, and money is a central question. Jessica remarks that finding this balance depends on the problem: if your solution does not depend on rollout in an academic center (less patient-focused domains, e.g. scribe solutions or orthopedics), performing a study at UCSF might be similar to any other hospital. In contrast, for more complex procedures like transplant surgeries, you may desire to be in a center with best practices in place to recruit patients and ensure optimal study design.

What do startups do wrong as they establish partnerships?

“A lot of times, it is not knowing what they are interested in. I really like the companies [that] come in with a study design and just need a faculty to help out. [These companies] know exactly what they want and want us to help out. I think the harder problem is a company wanting to do a pilot study, then wanting UCSF to agree to use their solution afterwards as a vendor. A pilot is at the research stage, but vendors are at the health system implementation stage. So when the expectations are different, it is hard for us to help them help us.”

Jessica stresses that transparency is key, especially because it is her job to work with founders to implement solutions. Founders that are clear from the start about budget, expectations, and involvement are much easier to help when trying to plan and execute a study or future partnership.

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