Not Another Twenty Years...

I know that everything is COVID-19 these days, but I don't know that I can read another article about it right now, and I certainly can't write one.  I need a break, and maybe you do too.  Instead, I'll talk about tech adoption and some lessons architecture -- yes, architecture -- might have for healthcare.  

Credit: Getty Images

The Wall Street Journal has an article Tech Disruption Can Take Decades -- Just Ask Architects.   Many of us knew that computer assisted design (CAD) had revolutionized the field of architecture, but until reading this article I did not realize that particular wave passed through the field in the latter  decades of the 20th century.  The wave that is currently passing through is something called building information modeling (BIM).  

BIM is 3D modeling on steroids.  AutoDesk, which I gather is to CAD and BIM as Epic is to EHRs, defines it as: "BIM is an intelligent model-based process that helps make design, engineering, project and operational information accurate, accessible and actionable for buildings and infrastructure." GRIFTISOFT, a competitor, says "BIM is the use of 3D virtual models of buildings, as well as a process of managing and collecting building data."  

In its BIM 101 article, engineering.com stresses that BIM is not just for architects and not just for design.  Instead, "BIM is all about the information. It doesn’t just create a visually appealing 3D model of your building—it creates numerous layers of metadata and renders them within a collaborative workflow."  

Keep that in mind for later.  

BIM didn't really start to take off until the last recession, when layoffs or fewer active projects gave architects more time to earn the software.  Not surprisingly, younger workers picked it up first, either then teaching other workers or assuming more duties and shunting older and/or less tech proficient workers to tasks less connected to design, "sometimes creating a complex generational dynamic."  

Phil Bernstein, a Yale architecture professor, told the WSJ this about BIM adoption:

I’m surprised by how slowly this is all happening.  When we first proposed the idea that Autodesk would shift from drafting platforms to modeling platforms, if you told me that almost 20 years later we’d finally be at the point where it was normal everyday practice, that’s a long time."

As one architect told the WSJ, "The promises of technology are oftentimes extremely exciting and encouraging when you hear the sales pitch.  The reality is that it’s a much longer and more complex process than originally envisioned."  

The article goes on to note:

The phenomenon holds lessons for other industries and trades, as digital tools offering more efficiency and precision replace older, more manual technologies. The barriers to adopting costly automation or technology can be significant, especially in fragmented fields with many small players.

Architecture has gone from a field marked by emphasis on drafting skills and reliance on reams of architectural drawings to one reliant on shared, dynamic, interactive 3D models infused with various types of relevant information.  In short, everything we should expect EHRs to be.

EHRs and telehealth are the two obvious parallels to CAD/BIM in healthcare.  Neither is a new technology.  Epic, for example, has been selling EHRs for forty years, and the VA's VistA has been in existence about as long.  EHRs have finally gained broad use, due in large part to the HITECH stimulus payments, but not deep satisfaction among clinicians.

Similarly, companies like Teladoc Health and American Well (Amwell) have been offering some form of telehealth for over fifteen years, and it is only with the COVID-19 crisis (darn -- I should have known I couldn't avoid it altogether!) that we are finally lifting some of the many barriers -- e.g., licensing, reimbursement -- that have kept telehealth from becoming mainstream.  

Of course, the fact that we have separate EHR solutions and telehealth solutions is an example of not fully embracing technological change (although some vendors are starting to integrate).  Similarly, the fact that we have telehealth solutions that are distinct from commonly used messaging/video services is another example that we're not fully maximizing available technology.

Healthcare has had many barriers to technological change.  Until fairly recently, most physicians worked in solo or other small practices.  Most hospitals were single location, nominally non-profit.  Home health agencies, nursing homes, dialysis centers, even drugstores were largely "mom-and-pop."  Most of that has changed to larger, more vertically/horizontally integrated models, but mindsets and technologies have not adopted as rapidly as business structures.   

And, of course, reimbursement has been a factor in healthcare technology adoption: there is a multiplicity of third-party payors using a byzantine medical coding system to pay an array of payment levels.  It can be tough to introduce new technology that doesn't fit existing molds and that may, in fact, slow processes during the learning curve.  

When you think about those older architects who struggled to learn CAD and then were forced to adopt to BIM, think about physicians spending hours trying to catch up on their EHR documentation.  A recent article in Harvard Business Review claims: "Estimates of physician productivity suggest that 20% to 30% or more of a physician’s available capacity is absorbed by clinical documentation, electronic medical record (EMR) inputs, and other compliance-related work."

Right now, you might say that healthcare is at the 2D CAD level.  Yes, we're moving away (ha!) from paper and more fully utilizing computers, but we're a long way from the 3D, interactive, information-embedded BIM that architecture uses.  

Imagine, for example, an EHR that:

• has a 3D model (digital twin!) of patients, annotated with pertinent images and information;
• is accessible and updateable by other clinicians as appropriate;
• is accessible and updateable by patients and patient devices;
• can be used as a communications vehicle with patients and clinicians

None of that technology is beyond our current reach, but I hate to think that it might take another couple of decades for such an approach to be in wide use.