10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

  

HEALTH AFFAIRS BLOG

RELATED TOPICS:
HEALTH CARE PROVIDERS | TECHNOLOGY | ORGANIZATION OF CARE | PATIENT EXPERIENCE
| HEALTH INFORMATION TECHNOLOGY | SYSTEMS OF CARE | VALUE | IMPROVING CARE
| FORMULARIES | ELECTRONIC MEDICAL RECORDS

Adopting Agile Principles In Health Care

Bradley H. Crotty, Melek Somai, Narath Carlile

AUGUST 15, 2019 DOI: 10.1377/hblog20190813.559504

The ever-increasing pace of technological advancements, rising

costs, and new entrants into the health care marketplace are part of
the challenge health care incumbents face today. With no alternative
but to adapt, health care organizations must nd effective methods
to embrace innovation, which we de ne as the delivery of new patient
and clinician value. Embedding and accelerating innovation in health
care, however, has proven to be di cult. In health care, most current
processes of governance, business planning, and information
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 1/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

technology implementation are designed to minimize risk to

organizations and are often in exible to adapt quickly to new
technological changes, netting incremental changes that fail to
deliver much needed transformation.

To address this complexity and speed up effective innovation, we

propose that health care organizations critically look at adopting a
novel set of principles, initially promulgated within the software
industry, called “Agile.” We have found that using Agile for important
transformative projects has enabled several health care
organizations, including ours, to begin to effectively adapt and adopt
innovation in patient experience, clinical work ows, and digital health
technology with the ultimate goal of improving care. Because the
core tenets of Agile include addressing the needs of customers and
embracing change, we see Agile being useful beyond projects related
to information technology to other health care domains such as
organizational strategy and clinical operations.  

The History Of The Agile Principles

The blueprint for Agile comes from the software industry. Before the
advent of Agile principles, most software engineering was typically
organized in a top-down approach, similar to the processes used in
health care organizations today. Customer needs were gathered and
outlined as speci cations, and architects created highly detailed
project plans that were then passed to engineers for development, to
quality assurance teams for testing, and then released to the users.
Projects followed this linear stepwise approach, often called
“Waterfall.” Since all customer needs were intended to be captured
during the speci cation phase, software engineers were often
separated from users. Furthermore, any subsequent deviation from
the initial speci cations was considered a failure of the process.
Teams lost the exibility to adapt to changing situations and needs,
or to incorporate new knowledge, tools, and technology. Engineers
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 2/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

themselves were demoralized, “being viewed as resources rather

than valuable participants.” Our experiences as clinicians, team
leaders, and team members in health care are comparable and
shown in alarming rates of burnout. From such frustrations grew
principles that radically changed the way software is now built.

In 2001, thought leaders in software development outlined a set of

principles, known as the Agile Manifesto. The document described
four core values supported by 12 principles that would guide future
work. The value statements are at the heart of the Agile movement:

Individuals and interactions over processes and tools

Working software over comprehensive documentation
Customer collaboration over contract negotiation
Responding to change over following a plan 

While both the left and right sides of these statements are important,
traditional business processes generally have focused on the right
side, such as following a plan and a structured process. Those who
wrote the Agile Manifesto noted, “While there is value in the items on
the right, we value the items on the left more.”

From these principles have grown multiple tools, techniques, and

implementation methods, but all re ect back to these four core
values and guiding principles. Agile has been credited with
accelerating innovation not just in the software industry but across
several others as well, including manufacturing, entertainment, and
logistics. Regardless of the speci c use case, Agile helps companies
move from a method in which everything is meticulously and
painstakingly planned to one that acknowledges, plans for, and
embraces change. 

Adopting Agile In Health Care—An Example From

Innovation

https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 3/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

Organizations may initially incorporate Agile methodology within

their innovation portfolio as a starting point. Innovation centers or
teams are often working on strategically important but high-risk
projects. In our experience, the transformational buy-in from senior
leaders is critical to developing space for Agile teams to form and
collaborate. To be successful, separate units within organizations,
such as business planning and information technology, must give
their staff freedom and exibility to join these teams. Recruiting
patients to be part of these teams ensures that the focus remains on
the people receiving services.

Indeed, innovation centers within health systems can be the initial

spark for Agile. For example, the Froedtert and the Medical College
of Wisconsin Health Network, where two of us (Crotty and Somai)
practice, created Inception Health in 2015 as a vehicle to accelerate
innovation through more rapid cycle project management,
contracting, and dedicated investment for innovation. The intent of
Inception Health is to catalyze and support innovation, supporting its
health system partners in areas of digital transformation,
consumerism, and precision medicine. While structured as a
separate limited liability company, the work Inception Health does is
part of the fabric of its member organizations, working with
operational leaders, key advisers, and front-line staff in a
participatory process. Inception Health has adopted Agile as its
backbone, forming teams of health system staff dedicated to each
innovation project.

A core tenet of our approach is that for each innovation, Inception

Health establishes an Agile team composed of clinicians, engineers,
managers, data scientists, and user representatives. Each team
establishes an iterative cycle to improve outcomes and the value to
patients, to the health professionals, and to the system overall. While
the core team comprises a handful of employees, several hundreds
of people from member health care systems have participated in
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 4/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

these Agile projects. By embedding Agile principles in the integration

process of innovation in the member health care systems, Inception
Health has been able to integrate innovations and iterate quickly. In
the past two years, Inception Health has implemented 26 innovation
projects at Froedtert and the Medical College of Wisconsin Health
Network, including online tools for behavioral health, diabetes
management, patient engagement, campus way nding, and remote
monitoring.

To enable clinicians to prescribe digital applications at the point of

care, Inception Health partnered with a company called Xealth to
create a digital health formulary, tying in third-party digital health
applications with the electronic health record and clinical work ows.
Inception Health implemented the software through Agile
methodology. An Agile team was created from members of Inception
Health to lead and manage the work, including care redesign and
informatics leads, analysts from Froedtert health information
technology (IT), and Xealth engineers. The team self-organized,
diagrammed work ows, and developed tests for the software and
implementation. The Froedtert health IT managers enabled the
analysts to work directly on this team, highlighting the role of
individuals and interactions over processes. Rather than being
viewed as a software vendor, Inception Health viewed Xealth as an
integral partner to building the future of its digital health capabilities,
highlighting customer collaboration over contract negotiation.
Clinicians in the “virtual care team” that would review alerts and
conduct remote monitoring participated in the design to ensure that
the system matched the idealized work ow. The team met weekly to
have “stand-up meetings” to review progress and active roadblocks.
The team frequently reviewed user experiences to respond to their
feedback. When system load times were not meeting expectations of
clinicians, Xealth and Froedtert engineers were able to understand
the problem and create a solution that would precompute digital
health recommendations based on the patient pro le, decreasing the
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 5/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

latency experienced during a clinical visit. As new technologies were

added to the digital health formulary, requirements changed,
including the requirement for integration into the scheduling
systems. The Agile team responded to these changing requirements
by extending the technical integration to meet these needs,
highlighting how the team was able to respond to changing
requirements rather than holding to the original proposal.

Traditional waterfall planning is not feasible for many projects such

as this because rapid iterations are required before achieving a viable
and scalable innovation. By shifting to Agile, teams work directly with
users for design and feedback, IT team members persist with
initiatives rather than moving off of projects after initial go-live, and
budgets and strategic plans are kept as exible as possible to
account for uncertainty inherent in the process. All these initiatives
were woven into the fabric of the health system using the Agile
methodology.

The values of the Agile Manifesto are fundamental to the team-based

work led by Inception Health. The teams do not follow prescriptive
practices or set tools, although do employ some organizational
frameworks such as scrum to plan work. Prototypes, or minimally
viable products, are prioritized to enable early launch and experience;
often, these are initially implemented in a small area to enable
improvements and gather data. Documentation in the forms of
work ows, training materials, or code development are created as
part of the innate process of collaborating, promoting sustainability
but with the initial intent on communication. For many of the external
partners, the teams aim for a partner relationship rather than being
simply a customer. Being built in a way that promotes agility, with
dedicated legal support embedded within the teams, Inception
Health offers a laboratory for companies to co-develop solutions. In
these ways, collaboration is prioritized over getting the most
favorable contract terms. Lastly, teams focus on vision and goals,
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 6/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

both short and long term, de ne key metrics and performance

indicators, and engage in iterative cycles of work. Teams pivot when
data and user reports show that tools or services are not being used
as initially conceptualized, or when user needs change.

The Broader Case For Agile Methodology In Health Care

Given their complexity and constraints, health care organizations

have more to gain from adopting the Agile methodology than other
industries. Health care organizations are inherently complex adaptive
systems, with several medical and non-medical professions working
in tandem with technology to serve the needs of almost any patient
who comes through their doors, within a constantly changing
regulatory and reimbursement system, and with rapidly accelerating
medical knowledge. Health care rarely, if ever, reaches a steady state,
resists reductionist analysis, and interacts with a constantly
changing environment. For these reasons, waterfall approaches are
often inadequate for achieving meaningful and sustained change in
health care delivery, something we see born out in the continued
suboptimal results of health care delivery improvement efforts, which
are expensive and cumbersome.

Most health care organizations today favor the right side of the Agile
Manifesto’s values statement. Organizational processes have been
developed out of need and experience, sustainability is paramount,
and budget and planning cycles often mandate that requirements
and contracts be stipulated far in advance of implementation. The
case for Agile is to nd new planning and management processes
that are capable of being responsive to changing needs while being
disciplined and accountable.

Health care organizations can accelerate the incorporation of new

ideas and the adoption of new knowledge through the following key
elements derived from the Agile principles: using user-centered

https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 7/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

design to clarify the problem(s) to be solved, key metrics, and

potential solutions; empowering a team to develop a rapid useable
prototype using a collaborative, disciplined approach and testing the
initial implementation of early work; and embracing new insights
from the users, external tools, and knowledge. Agile embeds
“testing” and “validation” as an integral part of the process. In
software engineering, Agile methodology led to the development of a
test-driven development, known as Test-Driven Work outside of
software, in which design and the development is guided by rst
establishing micro-tests that are validated perpetually.

For example, tests based around the design work and requirements
are created before the new program component is built, whether it be
software code or a new clinical work ow. Only after passing these
pre-speci ed quality checks would the program be deployed,
ensuring that what is built meets the speci ed user needs, integrates
with other components, and functions as intended. Tracking pre-
speci ed key performance indicators can then determine whether a
program component should be expanded or rolled back and
adjusted. This approach leads to more rigorous innovation that is
informed by a continuous evaluation. By embracing these principles
and a focus on providing value to the patient, Agile approaches could
help health care organizations capture and incorporate new
knowledge more rapidly and wisely. For those working in quality
improvement who are familiar with the Improvement Model, or Plan-
Do-Study-Act (PDSA) cycles, these concepts of measurement and
iteration will look familiar. 

Redesigning Health Care

Importantly, Agile methods are not limited to technology and

innovation projects, but are also valuable for clinical care redesign.
Agile could be used by teams to rethink the care model, starting from
and working closely with patients, their families, and communities to
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 8/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

ensure a care experience that is tailored to their goals and needs.

The Agile approach provides means to explore, integrate, and adapt
to new and emerging scienti c knowledge and tools, as well as the
chance to respond to changing patient and family needs and
expectations to create a truly adaptive, responsive caring system.
This Agile approach is used by innovative health care organizations
to deliver a patient-centric experience. An example is Iora Health, a
primary health care organization that focuses on building a team-
based primary health care service. Iora Health recognizes that health
care practice design is a dynamic process and uses an Agile
approach to iterate quickly to uncover better ways to design its
health care services. For instance, Iora Health built its own electronic
health records to respond to its Agile and team-based approach to
coordinate care. Iora Health’s leadership has written that “the
selection of Agile software development matches [its] clinical
innovation philosophy.” Geisinger’s “Innovation Architecture” provides
another example. Geisinger uses a methodology that resembles
Agile, incorporating cycles of testing and re nement to achieve
results that measurably improve care. Geisinger used this approach
for its medical home work as well as its ProvenCare program that
bundles services around a particular episode of acute care.

At the Brigham and Women’s Hospital in Boston where one of us

(Carlile) practices, teams within the Phyllis Jen Center for Primary
Care have begun using Agile to improve the patient experience. Staff
used an “Agile Clinical Innovation Practice” to reimagine annual
wellness visits for patients. The clinic empowered a team, focusing
on responsibilities rather than roles, to lead this work. Redesign
started using prototyping techniques, sticky note work ows, role-
playing with patient advocates to design the care pathway for
patients. The process underwent continuous rapid testing with
clinician leads who gathered feedback and iterated over all aspects
of the process. The design changed based upon testing and
feedback, including the testing of centralized and virtual pre-visit
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 9/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

planning services and processes to ensure inclusion of shared

decision making into visits. Agile facilitated these changes by
empowering a team to create the best experience for patients and
clinicians, doing rapid testing, and welcoming changes based upon
feedback, demonstrating how Agile enables a whole new experience
of designing, integrating, and improving care delivery. How was this
different from a tradition Plan-D0-Study-Act cycle? Instead of trying
to achieve an initial known goal, we pursued rapid innovation with the
intention of discovering—over the course of our work—the best
approaches to improving patient experience.

Role Of Leadership

Cultural adoption of Agile and related concepts are paramount to

both speeding the delivery of innovation and gaining acceptance of
processes that are not traditional within health care. To that end,
Inception Health has been focused on spreading a culture of
innovation throughout its organizations. Partnering with the Kern
Institute for the Transformation of Medical Education, more than 400
students, faculty, and staff have received formal training in design
thinking. Through initiatives such as an Innovation Faculty Fellows
Program, and in partnership with a local business school, Inception
Health has begun educating clinicians in additional concepts such as
lean launch and Agile. Design thinking and lean launch are building
blocks that use empathy and research to de ne problems and create
solutions. Agile methodology wraps around these concepts to ensure
that they have a disciplined and effective process to move projects
forward. Visible support from leadership critically supports
organizational cultures that not only tolerate but welcome new
frameworks such as Agile and the use of their related processes. 

Addressing Roadblocks In Health Care

https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 10/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

Several barriers challenge health care organizations seeking to adopt

Agile, but they are not insurmountable. Cultural changes are required
to enable Agile teams to form and collaborate, which can be
accelerated through visible support of senior leaders. Furthermore,
tensions can arise between the desire to close out projects and the
need for iteration and optimization. Paradoxically, these are not
mutually exclusive, and rapid, low delity prototyping using Agile
approaches can quickly bring clarity to the speci cations testing and
optimization of care services. Agile can coexist with traditional
business processes and be used at large, not just within innovation
centers or microsystems. Flexibility in deliverables and budget can
help Agile projects be plugged into annual business planning cycles.
For the Froedtert and the Medical College of Wisconsin joint strategic
plan, tactics that will use Agile are crafted to have built-in exibility.
Leaders are accountable for achieving the strategic objective rather
than a speci c deliverable. 

Conclusion

Agile principles compose a blueprint that could be adapted and

applied depending on the organization structure and philosophy.
Beyond internal projects, the Agile principles could be applied to
redesign the overall care experience. To fully grasp the value of
innovation and technology, we recognize that the redesign of the
health care practice is paramount. This integration could be achieved
through linking the process of care redesign and of the technology
innovation using Agile methodology. The Agile approach—if
embraced by health care organizations—will enable new Agile health
practices, allow care to be more adaptive and responsive to new
knowledge, improve care processes to deliver more value, and more
effectively adopt new technologies to improve the care of their
patients. 

Authors’ Note
https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 11/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

Dr. Crotty reports being an adviser for Buoy Health, a digital health
company. Drs. Crotty and Somai report working for Inception Health,
a liated with their primary employer the Medical College of
Wisconsin. Dr. Carlile is employed at Brigham and Women’s Hospital
and is a minor shareholder in ACT.md. Inception Health is an investor
in Xealth.

Related

CONTENT 

Organization Of Care

TOPICS 

Health Care Providers

Technology
Organization Of Care
Patient Experience
Health Information Technology
Systems Of Care
Value
Improving Care
Formularies
Electronic Medical Records

Cite As

“Adopting Agile Principles In Health Care, " Health Affairs Blog, August 15, 2019.
DOI: 10.1377/hblog20190813.559504

https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 12/13
10/1/2019 Adopting Agile Principles In Health Care | Health Affairs

7500 Old Georgetown Road, Suite 600

Bethesda, Maryland 20814
T 301 656 7401
F 301 654 2845
[email protected]
Terms and conditions Privacy Project HOPE

Health Affairs is pleased to offer Free Access for low-income countries, and is a signatory to the DC principles for Free Access
to Science. Health Affairs gratefully acknowledges the support of many funders.

Project HOPE is a global health and humanitarian relief organization that places power in the
hands of local health care workers to save lives across the globe. Project HOPE has published
Health Affairs since 1981.

Copyright 1995 - 2019 by Project HOPE: The People-to-People Health Foundation, Inc., eISSN
1544-5208.

https://www.healthaffairs.org/do/10.1377/hblog20190813.559504/full/ 13/13