The question Paul Black and Michael Dowling won't stop asking: Why can't it be improved?

In fall 2019, Northwell Health and Allscripts combined forces to create the next-generation EHR. The cloud-based, voice-enabled and AI-powered EHR will be designed based on input from Northwell clinicians, IT experts and administrators alongside Allscripts' development and systems integration expertise.

It's not every day a 23-hospital, 14,000 physician system partners with an IT solutions company to reengineer a piece of technology as ubiquitous as the EHR. Worth noting, too, is how the organizations aren't setting out on this effort quietly. The announcement of their partnership last fall made clear their accountability for results, not only at Northwell but the industry at large, by showing what's possible when EHR users and developers innovate together.

"I think the reason a lot of places don't do something like this is because they're consumed with day-to-day management," said Michael Dowling, president and CEO of Northwell. "Management is managing what is. Leadership is focusing on what should be."

Becker's Hospital Review caught up with Mr. Dowling and Allscripts CEO Paul Black to discuss the partnership, as well as the innovative philosophies and beliefs that drove them toward it. What follows is our conversation, lightly edited for length and style.

Question: How do you define innovation? Let's start there.

Michael Dowling: Innovation is about looking at everything you do and asking, "Why can't it be improved?" It's about having a culture that refuses to become a prisoner of precedence. It's a mindset, not a single project. It's making sure you have an entrepreneurial-type of culture throughout the whole organization, not just at the top.

Paul Black: A culture in which people think about things differently, like Michael said, is so important. Innovation also involves asking, "What should we not be doing?" Organizational habits accumulate over time. When people can't answer my question of why we do something, that's probably a good time to say, "Well, what would the impact be of us not doing that?"

MD: Some people also think innovation is finding that one big thing — one major development. Really, innovation is the multiplicity of small things, especially in a big organization. For instance, I spent five hours recently in the operating room with one of our top surgeons, who has developed a completely new method for a specific kind of surgery. He was operating on a particular part of the body one way for years, then figured there has to be a better way. For five hours yesterday I watched innovation in action, which came from one person who is part of a larger culture that questions the status quo.

Q: It's difficult to build this culture you've both described without a good number of innovative thinkers. How do you spot them? What gives them away?

MD: People who think they know it all are rarely innovators. I want people who are inquisitive and a little dissatisfied. I want to work with people who are constantly raising the bar higher than they think they can achieve. After all, it's much better to raise the bar high and miss it than set the bar low and achieve it.

PB: I agree with Michael on that point. I'm not looking for the smartest person in the room, especially if that person thinks that's who they are. I like people who truly have ideas and a voice, who have a track record of being able to excite others and bring them along in their way of thinking. People from outside healthcare can help us see things differently, since a lot of us have been doing this for 30-plus years. Whatever problem we're trying to solve, we put it in our Rubik's Cube of knowledge and come out with an answer. I like having people in the room who don't have that same formula of thinking.

MD: I'm looking for people who are excited to take on roles and responsibilities they've never done before. When someone takes on unfamiliar roles and duties, they often do so with fresh eyes and see things differently than their predecessors, which we stand to learn from. I seek out passionate people who enjoy taking risks — reasonable risks, that is. I also look for people who have an excitement about them that draws in other people. This can be found in the way they carry themselves, their personality, their team building and their prowess.

PB: Being inquisitive is also important. Are they readers? Do they think? Do they come up with new ideas in meetings? Do they bring up new ways of thinking about the problem we've all been working on solving? Those are the people I've historically awarded with much more responsibility. Part if this is about raising your hand and wanting more work, and getting it done, but part of innovation is also about building teams. Folks who are good at building the right kind of innovative culture — it shows in the teams they build. I like taking the best people from the outside, but I also like to promote people from within, which makes the team-building piece very important.

MD: One other thing — I want somebody with an optimistic attitude. Somebody who says, "It can be done. If you visualize it, if you dream about it, you can make it happen." Somebody who is perpetually optimistic. When things go wrong, they keep moving and don't get frustrated. You want people who are not afraid of failure, but are willing to learn from it and start anew the next morning.

PB: Yes, the person with the twinkle in their eye.

MD: Or the light bulb with the high watt. You want the person with the 100-watt light bulb, not 25.

Q: Setting out to build the next-gen EHR is a big undertaking and not for the faint of heart. What do you say to people who express doubt about your effort to transform a piece of technology, across all vendors, that's less than beloved by many physicians?

MD: There are always complaints about the EHR, in any place with providers. I think most people would argue that if you're going back to designing the EHR from the beginning, based on what we know today, you would probably do something different. You would create something much more conducive to your ability to actually provide improved quality of care to patients. The EHR is often limited in providing the kind of information we need to provide the comprehensive care people desire. That's a wonderful opportunity to break new ground and resist the constraints of what's been around for a number of years.

You've got to be able to look at the future and ask, "What do we think we need to improve healthcare outcomes and people's ability to stay well?" If you answer that, you are in the business of enhancing health, which means you need to be in the business of reforming the tools that help you do that. The EHR is one of them. If you aren't willing to ask this question, you're going to sit back and say, "This is too big. This is too difficult." Paul is an excellent partner who is willing to challenge the nature of his business. It's a pleasure to work with somebody who is not constrained by what is, but is focused on what should be. Few organizations, and few leaders, are wired that way.

PB: If we're successful with this effort, which we all expect to be, we'll be successful around the globe. That's one major benefit of having Northwell as a partner in this effort, in that we can do this at scale with the vast breadth and depth of their service lines. It's going to be a vision-meld between our two organizations. We're going to have issues, no doubt. Physicians are going to be lined up outside of Michael's door, and engineers will be lined up outside mine. When challenges come up, Michael and I will be getting on the phone or the plane to talk about it. We won't not simply say, "Ah well, we tried. We had a great experiment. Why don't we flip the page and try something else." No. This has to get done.

There's no question that both organizations are lined up shoulder-to-shoulder and leaning into this, to create something different for our doctors, nurses and patients. We want high fives from them when we're done, not people sitting back and complaining about the number of clicks or the fatigue they experience when using the tools. We take this obligation very seriously.

Q: It's clear you both have a strong sense of what innovation is and isn't. What are some common misconceptions about innovation that you feel are important to clear up?

PB: There's the question of how you innovate, then there's the question of how you just say, "I'm going to build an app, put it on my phone and hope that a bunch of people use it." I'm not dismissing apps, I'm simply saying they must be connected to something bigger and broader to really deliver sustainable, long-term value. Will that app be used five years from now or just for the first 15 minutes of its life? It reminds me of the dot-com bubble, when everything was really interesting and people were excited about the growing opportunities around the Internet. But just a few years later, most of those companies failed, shut down or went bankrupt. Apps are exciting in that they can start a conversation, but they are not innovation in and of themselves.

MD: Another misconception is that innovation is only stressed in the C-suite of organizations. You have to see whether the innovative culture is on the front lines. Even if a C-suite has innovative thinkers, can they transmit that throughout their culture? If innovation isn't happening on the front lines and in middle management of the company, it's not happening — that simple.

Q: I'm even a bit self-conscious in posing these questions to you, in that it's easy to talk about innovation like we are now. Actually doing it is another matter entirely. As leaders of organizations as large as Northwell and Allscripts, you can't afford lip service. How do you discern between the two?

MD: Most people will tell you they're innovative and have innovative companies. The word is used so often because the lingo is important. People constantly say, "I'm innovative." People in every organization I meet say they are innovative. It's important to make a distinction between organizations that talk about innovation and those that actually innovate, and those who have a culture that pretends to be innovative and those with a culture that is truly innovative. We have to be careful not to overuse the term.

PB: This is really where conviction comes in. There are a lot of well-intentioned people, who are former clinicians, trying to get something done because they've seen something big happen at one point in time that was avoidable. They thought, "Maybe if I could build a system or an app, I could prevent this from happening as it did to my family or to me." This is a group worth paying attention to, because there's a lot of really good ideas out there that people like Michael and I are always looking for. And these are the people who are passionate. They have the twinkle in their eyes. They really want to make a difference. They have much more conviction around doing something differently. I don't see a lot of that, quite frankly. Michael and I can sniff out your conviction pretty fast.

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