For a digital health startup looking to be deployed in a hospital, it can seem like finally landing that big hospital pilot is the culmination of months or years of effort. But hospitals and startups alike quickly learn that it’s just the beginning of a difficult process, and that many pilots die without being turned into full scale deployments.

“I think this pilot cemetery or death by pilot syndrome, there’s a lot of frustrations both at the practice level as well as the entrepreneur level, because it’s not getting us to where we want to be,” Meg Barron, director of digital health strategy for the American Medical Association, told MobiHealthNews. “Even when we have solutions that are proven to be evidence-based and trusted, like remote monitoring, there’s still a huge change management aspect to that, and getting the workflow down between a mix of the care team, physicians, patients and entrepreneurs.Trying to figure out what that secret sauce is is really difficult.”

Not only that, but sometimes pilots die even if the technology or intervention was working well, because the enterprise or the startup, or both, didn’t have the tools to make the transition from pilot to scale.

Build innovation programs for the long run

“Everyone can run a pilot. No problem,” Julia Jackson, currently the director of digital health at Sage Therapeutics, but until recently the managing director of the Healthcare Transformation Lab at Massachusetts General Hospital, said at an event earlier this year. “Ask yourself, next time you start an innovation project, what happens it it fails? Ok, kind of the norm. But what happens if it works? Do you have the infrastructure, the processes, the people, the champions, the administrative buy-in, the finances, and the creative legal team to actually take it to scale if it works?”

Dr. John Brownstein, chief innovation officer at Boston Children’s Hospital, noted that even programs designed to help startups succeed aren’t built to last in the right way — something Children’s strives to avoid.

“They don’t create long-term sustainability. They’re one-off and people are left hanging, especially with pilots that don’t get supported,” he said. “So we try to provide a long-term connectivity to those projects to their ultimate conclusion. Which could be that the project dies, which is a totally fine resolution. But it’s better for a project to die than for it to limp along into infinity.”

Partners HealthCare VP of Connected Health Dr. Joseph Kvedar noted that getting a project going long-term takes a different skill set than just getting a pilot started.

“One reason for the pilotitis is most people who want to move a pilot forward are doing so for the innovation value of it,” he said. “They want to be viewed as a person who had a bright idea, who brought a new way of doing things into the system. And by its very nature, we’re incredibly cautious. And maybe that’s for good reason, but it also makes the innovation cycle incredibly long and we just, we have that burden, that we are so cautious about messing up patient care that we tend to drag our feet from the end of pilot to the widespread adoption part.”

Have the hard conversations up front

The term “pilotitis” was coined years ago for the tendency in the industry to run a lot of pilots, but to be slow to turn any of them into a new standard of care. However, it is possible to “cure” pilotitis, and many leading hospitals have dedicated a lot of thought to doing just that.

Most of the innovation experts we spoke to agreed that the best way to set a project up for post-pilot success is to think ahead of time about all the potential pitfalls.

“My old boss used to say to me, Joe you can pay on the way in or you can pay on the way out,” Kvedar said. “You come to a committee meeting and you foist the decision on the committee you’re going to pay on the way out. But if you politic your way into a decision, you’ll have paid on the way in. This is a little bit like that. If companies can develop relationships with a chief medical officer or the chief financial officer, the innovator, the supply chain people, it takes forever, but when someone says ‘this really works’ they have an opportunity to move it to scale.”

Another conversation that needs to happen is about the price of the final product, even if the pilot is free.

“There’s been examples where we’ve done pilots with companies and they sound like great ideas to launch and scale but when we start to talk about pricing things go sideways,” Sunita Mishra, chief executive of Express Care at Providence-St. Joseph Health System, said at Health 2.0 last week. “So the best solutions are when we have these conversations up front and then we can start to work together.”

Make sure the tech will fit your hospital

Another issue that very often trips up pilots is when they don’t fit into a hospital’s workflow, culture and other aspects, including regulations, revenue cycle and branding.

“One of the most successful deployments we’ve had at scale, the team actually understood our strategic roadmap, they spent time with our informatics team, and then spent a lot of time with our clinicians,” Mishra said. “They understood, absorbed all that was going on there and came up with a product that allows clinicians to prescribe digital health programs that they can track through the EMR. And it helped on multiple levels with problems we had to solve.”

Other considerations include data privacy and HIPAA compliance, regulations, reimbursement, risk management, marketing, and even union rules, if an app effects the day-to-day workflow of nurses, for instance. Ultimately startups need to recognize that hospitals are complex places with many competing needs and stakeholders.

“The reality of realizing there might be different cultures within the organization is important as you’re developing the technology,” Omkar Kulkarni, chief innovation officer at Children’s Hospital of Los Angeles, said. “Getting to scale is more likely if you take that time to understand the different micro-cultures within an organization.”

Ultimately, hospitals need to commit to the long haul from day one.

“At the system level, we have made the decision that if one hospital uses a product, you will first make sure it’s deployable in other sites,” Dr. Pushwaz Virk, CMIO at 51-hospital system Providence-St. Joseph, noted. “That means if someone else needs that product, they don’t have to waste time on the sales cycle. That is something we’ve constantly instituted — more time up front, but once you implement it drastically cuts down.”

Kulkarni also noted that conversations that start out at the beginning of the process should continue throughout.

“If you’re really talking about going from pilot to scale, you need to get that feedback not only initially, but as different iterations go by,” he said. “I’ve seen on the flip side many really successful great ideas fail because you never really got that user feedback. What often happens is there’s one group really excited, you get a lot of their feedback, and then you assume that the rest of the hospital is going to have the exact same needs and exact same desires and exact same ways of doing things.”

Sherpas, champions, and project managers

Once a pilot is going, to give it the best chance of success it needs to be shepherded by relevant stakeholders. Innovators refer to these individuals by a variety of names — clinical champions, sherpas, project managers — but the general idea is the same. Someone with the right expertise who can take ownership and responsibility over the project.

“Everything that we do is driven by champions internally,” Brownstein said. “We may get excited about new opportunities, but if it’s not being driven by people on the clinical side that need it, it puts the project at massive disadvantage.”

The champion should be someone who knows the cultural ins and outs of the hospital, and is good at working with different stakeholders to get things done.

“So that sherpa needs to be able to navigate the institution,” Kulkarni said. “There’s a lot of politics involved. Maybe the doctor the startup reached out to is a very well-known doctor but has a political challenge. Little things like that can derail a project. And so innovation teams that are successful are finding ways to create as many pathways as possible to reduce some of these challenges, and that’s what we’re looking to do and what we have done in the last five months.”

Projects might need not only a clinical champion but also a project manager on the technical side.

“We have mandated that any project that impacts clinical workflow has a physician champion on it. The physician doesn’t have to be in every meeting, but it can’t go live without their approval,” Virk said. “It is always helpful if each startup provides a project manager even after the pilot has been done. Hospitals don’t have the project management expertise that is required typically, to carry your complex IT product to fruition. … I’ve seen some new technology in the operating room, the device company will have one of their reps handhold the surgeon for many, many weeks until they’re perfect. We need to have the same approach to IT.”

This leadership is more than a nice-to-have, Kulkarni said. It can be essential to a project’s survival.

“There’s a lot of projects that I’ve stepped into at Children’s where the people, the navigators that were present, ran into those roadblocks,” he said. “They had a pilot and then something happened. They couldn’t get it to the next level, they couldn’t go from that initial pilot to something that’s a little bit more representative of scale. And they kind of left it alone because it was too hard without that sherpa.”

The last mile

Massachusetts General Hospital has taken the idea one step further, and created an entire team whose function is to get projects over that gap between pilot and scale.

“If you give your shiny new thing to the enterprise, it will squash it,” Jackson said. “Hands down it will. So we actually created this thing called an extended pilot team at MGH and it’s an innovation in and of itself. It’s basically a team which will take it through it’s second year, when we’re not ready to kick it out of the nest but I can’t manage it anymore.”

But the best champion a project can have is the hospital leadership itself. Brownstein said that everything he’s done at Boston Children’s is only possible because of a pro-innovation culture that starts at the top.

“Unless you have real core buy-in from the top, that this is a must-do instead of a nice-to-have, I would say don’t take the job [of running an innovation program],” he said. “Because you’re going to be in a position where you’re just trying to get things done in an institution that’s trying to get all these other things done, that’s going to create a really tough dynamic and ultimately probably lead to a lack of success. If at the top level there’s not this belief that digital tools are a must-use in order for the organization to exist in the coming years, if that isn’t a firm belief, you can’t get anything done.