Health Care's Buggy Whips and Segways

In a thought-provoking piece, Joseph Caddell and Robert Stiegel warn of "misinnovation."  They talk about it in the context of national security and intelligence technologies, but health care should pay attention. 

By "misinnovation," they aren't talking about bad ideas, or even good ideas done badly.  Misinnovation is actually innovation -- just not the right innovation.  They characterize it into two immediately recognizable types:

• Buggy Whip Misinnovation: "innovating along a well-established technological arc for too long":
• Segway Misinnovation: "mismatching innovation to a need, often by jumping on the wrong technological arc"

The buggy whip problem goes back to the infancy of the automobiles.  Some people saw the future and bet on the new technology, while others thought buggies and buggy whips had served us well for centuries and would continue to do so.  They focused their efforts on making those as good as possible, not realizing until too late that they'd lost the market.

It's the old "what business are you in" question: buggies or transportation?

Dr. Caddell and Col. Stiegel cite the famous (and possibility apocryphal) Henry Ford quote:

Or perhaps better buggy whips.

Segways, on the other hand, were supposed to be the future.  Details of the secret invention were few and far between, but expectations were high.  It was said to be bigger than the PC, bigger than the Internet.  Seriously.

And what we got was, well, those goofy things security guards ride in malls. 

It's not that Segways are poor technology.  Far from it; they are pretty slick, and good at what they do.  It's not that they are of no use or that no one buys them.  It's more that not many of us think they solve a need that we have. 

When you think about it, misinnovation abounds.  Think about Microsoft introducing Zune just before the original iPhone was released, or the last generation of propeller fighter planes, that were immediately made obsolete by jets. 

Or, in an era of the internet, the companies who continue to improve the much maligned fax machine. 

Or upgrading stethoscopes (200 years old) and x-rays (125 years old) when portable ultrasounds, and ultra-low dose CT scans are available, respectively. 

Oh, that's right; faxes, stethoscopes, and x-rays continue in widespread daily use. 

In health care, misinnovation thrives. 

Health care has no shortage of innovation. There are plenty of innovators who are working diligently to bring new ideas to it.  The innovation is coming both from within the industry and from other industries.  We see innovations like wearables, Big Data, gene therapy, nanobots, 3D printing, to name a few.  It's an exciting time to be in health care.

What we don't see is enough thought and discussion about which of these are truly innovation and which will, at some point in the future, be viewed as misinnovation.

Let's think about the two types of misinnovation as they relate to health care.

There is a lot of money spent on "reinventing" hospitals. There is much effort on redesigning them to improve the patient experience.   Politico just ran a series of articles looking at the future of hospitals, such as virtual hospitals, McHospitals, more community-oriented hospitals, even hospitals less focused on beds.  UPMC announced they were spending $2b to revamp its hospitals into "digitally based specialty" hospitals.

These are all well intentioned, may help patients -- but fall into the "better buggy whip" category.

Hospitals are curious places.  We put a vulnerable people together with people who have often exotic  germs.  We put debilitated people into environments where they often become even more debilitated.  We put people who need care and comfort into emotionally sterile settings with not enough staff to give it to them.

We don't need better hospitals.  We need the thing that will take the place of hospitals.

Similarly, there is a revolution in smartphone-based apps for health care.  The list of things you can now do on your smartphone is amazing.  For years, Dr. Eric Topol has been evangelizing what they can do now and will increasingly be able to for our health.  If you're not impressed and astonished, you're not paying enough attention.

This is all exciting.  It's helping democratize our health care, and may even help improve our health.   And it fits into the Segway category.

There's a need for more ubiquitous monitoring, analysis, and advice in health care, but simply putting more apps on our mobile devices is not the solution.  We don't need fifty -- a hundred! -- health-related apps telling us how we're doing and what we should do about it.  We certainly don't need competing apps that give us conflicting results and/or advice.  We don't want to have to pick the right apps to ask the right question in order to get the right answer.

We don't need more apps.  We need the thing that makes sense of what they can tell us.

The list could go on and on.  Invasive surgeries or intensive radiation therapy are buggy whips.  More kinds of long-term use prescription medicines are Segways. 

If we're doing damage to the patient, even in the interest of curing them, it is an approach for which we should be thinking about alternatives.  If we're doing things that help people live with their condition or limitation, we should be thinking instead of how to get rid of it. 

Try to think about what we're doing as someone from the future might look at it -- like Star Trek's Dr. McCoy finding himself in 1986:

We're not in the 23rd century.  We don't have those kinds of technologies yet.  But we're not in the 20th century anymore either, much less the 19th century.  We should be looking at technologies and approaches from those times with great skepticism, and not spending too much time further innovating them. 

Our innovations should be more recognizable to someone from the 23rd century than to someone from the 19th.

Nor should we be doing cool things just because they're cool, as Kirti Patel recently put it.  We should be doing things that consumers need and that will help them be healthier.  We have a health care system that seems like it would rather put someone in a fancy motorized wheelchair -- or a Segway! -- than to get them to walk more while they still can. 

I love innovation.  Health care needs it more than ever.  But let's try to be sure it actually is innovation, not misinnovation.

Sunk Costs Are Sinking Healthcare

Peter Drucker is often credited with the famous expression "culture eats strategy for breakfast" (or lunch).  In other words, you can have all the visionaries you want, brainstorm the greatest ideas ever, and develop very snazzy Powerpoints, but if the people responsible for making the strategy actually happen either don't know how to -- or simply don't want to -- carry it out, well, forget about it.

Dr. Brent James, the Vice President and Chief Quality Officer for Intermountain Healthcare, goes Professor Drucker one step further: "If culture eats strategy for breakfast, then infrastructure eats culture for lunch."

As NEJM Catalyst explained, "In other words, infrastructure lays the foundation for culture."

Infrastructure in organizations dictates much of how things get done in them.  It enables most of the organization's tasks.  It is essential.

However, infrastructure also often defines what people in organizations think can be done, perhaps even what should be done.  Much of this is implicit rather than explicit.  People don't always recognize how their underlying infrastructure shapes their perceptions of not only the existing but also the possible.

This is a problem for health care.

We have hospitals, so we must try to fill them; not only that, we need to make them even bigger.  We have scanners, so we must use them.  We have new drugs or new devices, which are all-too-often at best only marginally better than existing ones, so we must start giving to patients.  We develop new surgical procedures, so we compete on who can start doing the most of them the soonest, not always even pausing to ask if those surgeries are necessary or appropriate for all the people who end up getting them.

We have funding mechanisms that don't work well even for the people who have access to them, so of course we try to give access to them to more people.  We have health plan designs that no one really understands, so we keep making them even more complicated (anyone know what a Tier 4 non-network drug is, or why there is such a thing?).  We have bills that can at most charitably be described as incomprehensible, so we're adding more procedures and more codes to make them moreso. 

We have EHRs that everyone hates and many think actually interferes with patient care, but we rush to extend them.  We have billing systems and claims processing systems that are in a figurative arms race against each other, the former seeking to enhance revenue while the latter tries to impede those efforts, even at the price of impacting people's care, so we keep pouring more money into each.

We buy up hospitals and medical practices in the name of integration and/or efficiency, even though there is precious little evidence that such consolidation does anything except to raise costs.  The infrastructure just gets bigger and more bureaucratic. 

 We spend over $3 trillion a year on our health care system, as wildly inefficient as it is and as much wasted care as it delivers, and yet we're putting ever more into the infrastructure that supports it. 

There is in economics something called the "sunk cost fallacy."  This comes when people or organizations continue behaviors mainly because they've already invested so much in them -- whether that investment are dollars, time, or effort. 

The more of any that are "spent" on something, the more reluctant people are to admit that perhaps it is time to stop such spending. 

Sound familiar when thinking of health care?

People think we're spending too much on health care and on health insurance.  Clinicians are frustrated with their administrative burdens, and admit that there's significant overtreatment.  Politicians on both sides argue that the existing system isn't working, but neither offer any fundamental changes to it.

Yes, spending on health care technology is booming.  Yes, there are plenty of health care start-ups who ostensibly seek to "disrupt" the health care system.  But, are they remaking our health care system? 

No, the existing health care infrastructure is eating their breakfast, lunch, and dinner.

I'm as big a believer in technology and innovation as anyone.  I believe that, at some point, the health care system will get disrupted, in ways that we're not thinking enough about and that can lead to healthier lives, at lower costs (not just lower rates of increase),. 

But our sunk costs about how we think about health care are limiting us.  Our existing infrastructure is so large and so complex that the prospect of truly getting rid of major portions of it is too daunting for almost any innovator.

After all, with $3 trillion in play and known inefficiencies, it is much easier to make money -- and to get investors -- if an innovator can figure out how they can make just some small part of it just somewhat better, and keep a sliver of all that spending for themselves. 

Imagining and implementing a whole new infrastructure is a lot harder, and a lot riskier.

The analogy is already overused, but still instructive: Uber and AirBnb didn't reinvent their industries by pouring money into the existing infrastructure of the taxi and hotel businesses, respectively.  They imagined a whole new business with a distinct (and less capital-intensive) infrastructure. 

So forgive me if I don't get excited when, say, UPMC invests $2b into new hospitals, Epic is switching to CHRs, or Roche is putting $11b into R&D.  I don't expect to see new paradigms for our health care system to come out of that kind of spending, nor do I think my health care is going to get any less expensive.  Or that I'll become any healthier.

Done right, infrastructure can, indeed, help "cure" health care, as Enmi Kendall and Anya Schiess wrote earlier this year.  Done right, changing the culture within health care will make it possible for us to change the system and its infrastructure.  But neither one of those is easy and neither is a given to happen. 

The first step in digging oneself out of a hole is to realize that you are sunk in it.   

Patients Are a Design Problem

When I say "patients are a design problem," I don't mean that the people who happen to be patients are a design problem.  They may well be, but that's an issue you'll have to take up with Darwin or your favorite deity (or, all-too-soon, perhaps a CRISPR editor...).

No, I mean that making people into patients is a design problem.  And it's a big one.

Over the last twenty years, there has been much discussion and debate about whether patients are, or should be, actually "consumers."  But I've never met a doctor or other health care professional who thinks of the people they treat as "consumers," or, in fact, as anything other than patients.

The term "patient," referring to people getting medical treatment, has been in use for hundreds of years.  It is not a coincidence that it is related to being "patient," that is, suffering without complaint.  No wonder medical professionals like to use it.

There have been many calls to change the word -- see, for example, Pat Mastors or Julie Neuberger -- but what we have is deeper than a semantic problem.  Changing the word we use to describe people caught in the health care system doesn't change the dynamics of that system.  A new word would not change how such people are treated or have come to act.

This is a design problem.

Consider the following:

1.  Physician Respect: We treat physicians as something special.  We hear about how difficult it is to get into medical school, how tough the process of being trained as a physician is, how hard they work, and how much they need to know.  We watch them perform miracles routinely on television, and expect our own physicians to have the empathy of Dr. Welby (some of you may have to ask your parents), the encyclopedic knowledge and keen intuition of Dr. House, and the technical prowess of Dr. Shepherd (some of you may have to ask your wife or girlfriend).  That white coat is no longer needed and may, in fact, be counterproductive, but serves to remind of us the deference the health care system believes physicians are due.
2.  Patient experience: It's hard to get appointments.  The appointment time is often just a vague indicator of when we'll actually see our doctor.  We may have to put on an embarrassing gown and get up on an uncomfortable table.  We may have services done to us that we don't really understand and which not uncommonly are unpleasant, to say the least.   We may be asked to fast unnecessarily for hours before blood work or procedures.  We often are unsure about what is going to happen next, or when. It is not a patient-centered system.
3.  Medicalization:  We talk about the health care system, but we really mean the medical care system.  We almost never include, or pay for, the other things that impact our health, like diet, exercise, and environment.  Instead, we seek our health care providers for our health issues and advice, to the point where some physicians now give out "prescriptions" for exercise.
4.  Better, Soon: We've seen remarkable strides in what medical care can achieve, such as antibiotics, polio vaccines, organ transplants, joint replacements, pacemakers, chemotherapy, and advanced types of imaging, to name a few.  We have become a nation of pill-poppers.  When something is wrong with us, we expect to be able to get it fixed, and we expect that to happen quickly.
5.  Confusion reigns: Nothing about health care seems easy.  It's hard to pick a physician, or a health plan.  The terminology makes no pretense at being understandable to anyone not a health care professional.  The bills are practically indecipherable, especially since the pricing behind them is intentionally opaque.  If you need multiple doctors, tests, or procedures -- which you almost certainly will -- you'll have to navigate the maze around getting them.  No one, lay or professional, claims to understand the "system."
6.  Responsibility: We've delegated responsibility for our health to our health care professionals, especially our doctors.  It is more established than ever that regular exercise, moderate eating, and a balanced life would do more to improve our health than any regime of medical treatments.  Yet we continue to expect that the results of our increasingly poor habits will be "fixed."

These are why we are "patients."  These are why we are expected to be patient.

There are constant calls to reform, even disrupt, the health care system.  There are new entrants, new models, new technologies, and plenty of new money.  As I wrote a few years ago, though, most innovations in health care seek not to disrupt the health care system, but to get their share of the spending.

A new article by Clayton Christensen and colleagues points out:

more than $200 billion has been poured into health care venture capital, mostly in biotech, pharma, and devices where advances typically make health care more sophisticated — and expensive. Less than 1% of those investments have focused on helping consumers to play a more active role in managing their own health, an area ripe for disruptive approaches.

Their article highlights Iora Health, while, in another series of articles about disruption, Robert Pearl, M.D., is keen on CareMore, Forward, and Health City.  But none, in my opinion, go far enough.  None redesigns the "system."  None really tilts our system away from medical care system and towards empowering people to take charge of their own health.

We will always need physicians (although not always human ones!), and many other health care professionals.  That's a good thing.  They have knowledge and skills that can help us.  They deserve our respect.

But we should design our health care system around us, not them.

Make the "system" simpler.  Focus it around our health, not our care.  Expect us to have responsibility for our own health -- but ensure we have the tools we need to manage it.  Spend money to prevent health issues, not address them once they've happened.

It won't be easy.  We don't know how to motivate people to be more responsible about their heath, to the point we're excited about digital pills that track whether we take them.  Nifty technology, but I wish we invested more in the underlying problem(s).  Let's make Professor's Christensen's 1% more like 90%.

If patients are a design problem, then maybe people can come up with a design solution.

Bjork, Blockchain -- and Healthcare

Healthcare should pay more attention to Bjork.

To be fair, I think everyone should pay more attention to Bjork.  I've loved her since she was in the Sugarcubes.  Her voice is astonishing, her music is always interesting and often magical, and when she sings she commits more fully than any other singer.  If her fashion sense is sometimes out there, well, we expect some eccentricities from our geniuses (and, oh-by-the-way, that infamous swan dress is now honored in a museum). 

But all that aside, health care should be paying attention to how Bjork embraces new technology.  That now includes blockchain.

With her latest album, Utopia, due to be released later this month, Bjork is teaming with blockchain company Blackpool to use blockchain and, more specifically, crypocurrency to try some new things.  As reported by Musically, fans can:

• Pre-order the album using several different kinds of cryptocurrencies, such as Bitcoin or Audiocoin, along with more conventional forms of payment.
• Earn 100 Audiocoins -- worth $0.19 currently -- just for pre-ordering.  The digital coins will be deposited into a e-wallet, and can be exchanged for other cryptocurrencies, converted into "fiat currencies (like dollars), or kept for future use.
• Receive additional Audiocoins by interacting with Bjork and her music, such as attendance at concerts or perhaps promotion on social media.  
• Use their Audiocoins to buy additional Bjork music or related materials.  

It wasn't explicitly spelled out but presumably the fan participation will be tracked using blockchain.

Bjork and Blackpool will develop more details about how fans can earn and use their cryptocurrency over the next couple years, but it certainly is a unique approach.  As The Next Web put it, "at the moment it just kinda sounds like a hybrid between a CVS pharmacy rewards card and a fan club. That’s not necessarily a bad thing."

Blackpool CEO Kevin Bacon told Musically:  

You could create blockchain-enabled digital treasure hunts, although what we don’t want to do is turn this into Pokémon Go! But why not reward your fans for engaging with what you do, and reward them in a meaningful way?

Keep in mind this isn't the first time Bjork has creatively used technology in conjunction with her music:

• She made a critically acclaimed video ("All Is Full of Love") featuring robots -- in 1998.  
• In 2011, Biophilia came as a standard audio version but also featured a collection of apps that transformed the audio experience.  MoMA included the app as the first downloadable app in their permanent collection, noting: "With Biophilia however, Björk truly innovated the way people experience music by letting them participate in performing and making the music and visuals, rather than just listening passively."  There is now also a Biophilia Education Project to help inspire creativity in children.
• A subsequent album, Vulnicura, led to a virtual reality (VR)-based exhibit also expanded the musical experience.  It has appeared in major museums around the world.

Bjork may be not just a genius with her music but also in using technology to change how we experience it.

I have previously written on why and how bitcoin, blockchain, and even smart contracts might be used in health care, but to pretend that I actually understand any of them would be overstating the case, to say the least.  Fortunately, more knowledgeable people in the field are increasingly coming up with applications for it, as a recent synopsis in HealthIT Analytics illustrated.

Let's think, though, about how Bjork's latest experiment could be translated into health care.  Imagine, for example, a direct primary care practice (DPC) that:

• Allows/encourages patients to pay for their services using crypocurrency;
• Uses a smart contract to establish the mutual obligations, the agreed-upon measurements for "success," and the mechanisms for performance-based rewards/penalties;
• Tracks patients' behaviors (preventive visits, exercise, etc.), readings (vitals, labs, etc.), and records (diagnoses, treatments, etc.) using blockchain (a blockchain EHR!);
• Allows patients to earn additional cryptocurrency for meeting desired health goals and/or activities.    

I used DPC as the example because the fixed monthly fees may be easier to work with than fee-for-service, but there is no reason a similar approach couldn't be used for health plans, health clubs, or even fee-for-service providers.  

Bjork's blockchain-based :"CVS rewards card/fan club" that rewards fans for a variety of desired types of involvement is particularly intriguing.  Applying the concept to health care would help recognize that most things impacting patients' health happen outside of health care settings, and could create ongoing, visible, positive incentives for patients. 

Not just DPC; Fitbit and Apple Watch: are you paying attention?

We're not going to transform the entire health care system into blockchain immediately, nor should we.  There are still too many unknowns.  However, experimenting with it within a moderately closed environment like a DPC practice might be a great place to start. 

Blackpool's Kevin Bacon has a great perspective on blockchain:

There’s a lot of talk about whether crypto and blockchain is a bubble. I don’t see it as a bubble: I see it as a burst of energy. I think you’ll see a lot of activity, a lot of things will disappear or get left to rot, but the important things will stay and grow. 

I think blockchain and crypto will be like the dotcom boom and bust in the late 1990s. We’ll see enormous adoption over the next couple of years, then some kind of bubble burst, but then a long-term change.

Blockchain won't solve the health care mess we find ourselves in, especially in the U.S.  There are too many fundamental issues that we need to address.  What it may do, though, is give us a new set of tools to help solve it.  We need to see that boom and bust that Mr. Bacon refers to, and see what uses are left standing.

I'm looking forward to hearing more about what Bjork does with her new initiative, and I hope some health care organization takes note.

Meanwhile, I can't wait to see how Bjork will use what Fast Company says may be the next iteration of the Internet itself -- Dispersed Computing.   But that's a topic for another post...