Necessity: Invention's mom

Apparently, the quote about necessity being the mother of invention is a bastardized version of a line from Plato's Republic, “Our need will be the real creator.”

Thanks, Wikipedia.

I’m not sure that necessity drives anything, but it definitely helps people focus.

And we can learn a lot about our areas of collective focus based on an examination of what works.

Every single health system in the country has a financial department that is at least semi-functioning. Every EHR I have come across — and there is a special locked annex in my memory for all this; one of Dante's circles of hell — has a UX that seems to have been initially conceptualized as a practical joke or some sort of punishment or enhanced interrogation or something. But, the billing works.

If it doesn't, it gets fixed, quickly. We might be using a pen-and-paper workaround for prescriptions for years, and making an appointment in a large medical system is like taking a phone-based standardized test while on some bad acid, but man… those bills seem to make it to the right place.

If Covid did anything, it showed us how fast we can move when our existence requires it. The telehealth revolution that many people thought would take ten years took three weeks. Even the most old school, Father Martin chalktalk, “accountability-driven,” Jurassic-epoch programs were rocking virtual care. Our survival depended on it. Our patients’ survival would have benefitted from this anytime over the last ten years, but it just wasn't our primary focus.

Take the fax machine. Even Covid couldn’t kill it.

The technology used for communication in combat theaters and in multibillion-dollar financial transactions wasn’t secure enough to comply with HIPAA? You don’t think a universal standard for encrypted communication wouldn’t have dethroned the healthcare GOAT if we needed it to drop a bill?

Why is this the way it is?

Making this interagency communication easier for both patients and providers just isn't the focus.

How long would it take for us to change if our reimbursements still ran on fax?

How killer would our EHR interoperability be if we needed it to get paid?

It’s all about focus.

Innovation requires focus in context.

I remember the point in my career when I was first getting exposed to the pieces which make up our systems of care. I felt like I was standing right up against some massive object. I was so close I could feel it, but I was too close to know what the hell it was. I just knew what it felt like — what its granular parts looked like and how they worked at a micro level.

I felt like I spent the next couple years walking backwards trying to get a view of the entirety of the thing. I’d have to learn what the hell a 340B program was and why it made any difference in the great catchment battles raging between the local FQHC and community mental health center. I had to learn why the local jail didn’t test for Hep C or HIV and how that was connected to some arcane Medicaid rule. Why is what Bill and Bob wrote in the early 20th century relevant to prescribing buprenorphine in the 21st?

I felt like I was riding a rocketship of a learning curve, but finally it started to feel like I could see something that resembled a complete picture.

It wasn’t and isn’t that simple of course, and everything is always changing and expanding, but for me, this context and global setting is the prerequisite for innovation, especially in healthcare.

This universal (*universal-ish, more like) setting allows us to begin with a very, very specific focus. This to me is the key to innovation: an atomic-level focus within a massive, universal* context.

With this sort of contextual understanding, we can start with a manageable set of problems and test low-risk, simple, iterative solutions.

Let’s take one of the biggest, gnarliest issues we face in our work: Roughly ninety percent of people with an SUD don’t receive care. We know that. We have some insight into why. We have some things that are working. But, what if we just poked around for a bit on this?

What If we could find one person who would fall into this category? Where might they be? How might we find out what they think they need? Who might know that this person might have a problem, even if they didn't?

What If we could find five of these people and repeat the process? What If we did it over text? What If along the way, we found what amounted to some human bloodhounds who had a creepy and somewhat mystical ability to get connected with these folks?

What if there were weird places that had nothing to do with anything related to substances but were absolutely filled to the brim with folks who screened positive? Are there people who act like magnets in a way that's similar to these places?

Why do some people make contact with lots of people looking for help? What makes them uniquely helpful? How many of these people might there be? How can we find them? Can we make more? Can we use technology to make them accessible 24/7 across the country while paying them a living wage?

Can you feel the thread?

I think part of our problem when we try to unpack some of these giant, wickedly complex issues is that we aren't able to focus. We are constantly reforming a solution that wasn’t purpose-built for the issues we are facing. It’s the wrong focus entirely. We have a rube Goldberg machine constructed from things that 3-year-olds would find on the ground and think are magical, musty family heirlooms, and 60 years worth of duct tape.

Maybe part of our issue is that our focus has been on issues that aren’t necessities? We have focused for so long on approaches that have been successful, as far as they go, but if we are able to be uncomfortably honest with ourselves, they aren’t really necessities. It’s time to recalibrate and reimagine.

JCAHO and HEDIS and ICD 10 codes are cool, but I dunno… Are they going to somehow turn out to be the answer to our shared, horrific existential crises? Are we really going to rise to the level of moral and spiritual action that this moment requires of us through manualized CBT delivered by miserably underpaid clinicians over telehealth?

Maybe people could use a safe place to stay, a couple friends and some dignity and meaning? I’m not sure…

I do feel pretty sure the best way to get started is to start.

It doesn’t have to take years. It doesn’t require massive amounts of funding. Most of the people who are any good at it are too annoying to be of much use to most institutions, so you can usually find some people to help out.

My experience is that innovation isn’t contrived. It is annoyingly slippery. It is paradoxical. In lots of ways, it’s often stupidly simple. Sometimes it is counterintuitive. But for me, it tends to show up when we mix a global understanding with a very specific focus for our curiosity.