Open Source Goes Corporate

If you aren't in IT, you may have missed the news that IBM is acquiring Red Hat, a leader in the open source Linux movement, or that, a couple days prior, Microsoft closed on its acquisition of GitHub, a leader in open source software development. 

Earlier this year Salesforce acquired Mulesoft, and Cloudera and Hortonworks merged; all were other open source leaders.  I must confess, I had never heard of some of these companies, but I'm starting to believe what MarketWatch said following the IBM announcement: "open source has truly arrived."

What exactly that means, especially for healthcare, I'm not sure, but it's worth exploring. 

Credit: Red Hat

IBM is paying $34b for Red Hat. Their offer is a 60% premium for Red Hat's stock, and the acquisition is IBM's largest ever -- and the third largest in U.S. tech history.   Red Hat is a leader in Linux, an open source operating system, and has been around since 1993.  Linux has become a preferred operating system for cloud computing, for which IBM has big ambitions but in which it trails competitors like Amazon, Microsoft, and Google. 

Red Hat has many healthcare clients, including Cerner, and IBM had already made healthcare one of their key priorities. 

IBM sees the future of cloud computing as a "hybrid" approach, in which they help companies use both in-house cloud platforms they control and outsourced cloud platforms.  Paul Cormier, Red Hat's president for product and technology asserts: "For most corporations, hybrid cloud is the only practical way to the cloud."  

Culture may be an issue.  Red Hat has what the Wall Street Journal described as a "more freewheeling corporate culture."  It quotes one employee: "There’s still a very passionate core at Red Hat who really believe in the open-source mission."  IBM's CEO, of course, vows to keep Red Hat's culture.  

GitHub is a repository for open source efforts, hosting code, documentation, and even whole projects.  At the time of the acquisition, it claimed to have 28 million developers, with 85 million repositories.  

HIT Infrastructure noted that GitHub has many healthcare users, citing the source code for healthcare.gov and open source code for Epic and Cerner.  

Microsoft historically was seen as opposed to open source, including Linux, but CEO Satya Nadella continues to push their culture, and it had, in fact, been a major user of GitHub (as are, for example, Apple, Facebook, and Google).  

Rather than the deal scaring developers away, GitHub now says they have 31 million developers.  Their now-former CEO emphasizes that GitHub will operate independently and keep its product philosophy, while its new CEO says: "Our goal is to help GitHub be better at being GitHub, and if anything, to help Microsoft be a little more like GitHub."  

Speaking specifically of the IBM - Red Hat merger, Jay Lyman, an analyst at 451 Research, said:

With this being a validation of open-source software, this might make any number of companies based heavily or centrally on open source more attractive, or face less trepidation from businesses spending money on open-source.

In other words, expect more open source deals -- and more open source generally.   As Red Hat's Paul Cormier proclaimed: "Today is a banner day for open source. The largest software transaction in history and it’s an open source company. Let that sink in for a minute. We just made history."

Phil Fershy, founder and CEO of HfS Research, agrees: "forget about the cloud, this is all about Open Source."

It may be open source's time.  For example, Joseph Jacks founded OSS Capital to focus specifically on funding open source efforts.  In an interview with SiliconANGLE, he asserted: "We believe that open-source software will always generate or create orders of magnitude more value than any constituent can capture."  OSSC's motto is "open source software eats everything."  

Let that sink in for a minute, or two.  

People don't often think of healthcare when they think about open source.  They more often complain about silos, lack of interoperability, home grown solutions or one-size-fits-all solutions from huge HIT companies.  "Open source" sounds to many healthcare executives like something hippies might do, not HIPAA-responsible firms. 

Perhaps that is changing.  One recent survey found that healthcare, for example, found that healthcare was further along than most industries in moving to the cloud, with 31% of respondents storing more than 50% of their data and infrastructure in the cloud. 

We now have an Open Source Healthcare Journal, in whose debut issue Eric Topel, M.D., noted: "Open source is fundamental. The fact that we don’t have open healthcare reflects the deepness of our problem." 

Tincture contributor Jane Sarasohn-Kahn is also featured.  As she said in her blog:

When computer systems are closed or siloed, when data aren’t transparent, or when people can’t access the information they need in real time, then those folks can’t make fully informed, rational decisions.  

In health and healthcare, that's tantamount to keeping medicine from sick people -- because in today's data-fueled environment, information is power in the hands of people, patients, consumers, and caregivers.  

The journal is backed by healthcare design studio GoInvo, whose Juhan Sonin said: "GoInvo is designing the future of healthcare, and we think that future is open."  

He went on to say:

We demand that our healthcare services be open to inspect and correct bias, and to be accessible for rapid innovation and evolution.  Together with leaders and progressive thinkers in digital health, we are beginning a dialogue about open source in healthcare. We need to put a fine point on a mission critical part of our healthcare system, that is dominated by closed services, limited access, lack of transparency into pricing, and no patient-data ownership, which impacts all of our health.

Healthcare may be making progress, but not enough, and not fast enough.

A cynic might look at these recent acquisitions/mergers and say, well, the big corporations have won the war, absorbing the open source movement inside them.  An optimist might look at the same and say, the war's not over, but open source is winning the battle, making even Big Blue and Mister Softee adopt to them.  

Time will tell.  Culture will matter.  The question is, will healthcare absorb open source, or adopt to it?    

The Future of Healthcare May Be...Sears?

I can't stop thinking about Sears, which, in case you missed it (or don't care), has declared bankruptcy.

Like many of my generation, Sears was a staple of my childhood.  It was one of my father's favorite shopping destinations.  It was at the local malls.  You could buy practically anything there.  And, also like many of my generation, I haven't shopped there in years.

Sears wasn't in the healthcare business -- how did they miss that? --  but its decline may have warnings for it.

Photo: Lori Van Burenn

To be fair, Sears is hardly the only department store to be going through hard times, and, like Toys-R-Us, its current financial straits reflect more of its leveraged buyout than to any underlying changes in consumer purchasing preferences.  But Sears was different; Sears was iconic.

Sears was once the nation's largest retailer and employer.  Moreover, as CNN put it: "In its heyday, it was both the Walmart and Amazon of its time."  Pretty heady praise, but it was not only big, it was extremely innovative.

Its catalog was the internet of its day, allowing customers in the furthest reaches of the country to see, price, and buy products that they never otherwise would have even been aware of.  Its appliances (Kenmore) and tools (Craftsman) were top-of-the-line.  You could literally buy a kit for a house from them.  Sears quickly followed its customers to the suburbs after World War II, establishing anchor presences in most major malls and expanding hours.  

Sears even jumped big into financial services, founding Allstate, launching Discover, and buying Dean Witter (although it subsequently shed all three).

Somewhere along the way it lost that verve.  Big box stores like Home Depot and Walmart undercut it on prices, it missed badly on the internet, and it lost its ability to gauge what products consumers wanted.  It has closed over 1,700 stores in the past decade and it took its name off the Sears Tower in 2009, so the actual bankruptcy didn't come as much of a surprise.

Jason Downey, founder of the Center for Generational Kinetics, put it this way to USA Today: "Sears basically invented the catalog, and yet we have millennials who don't even check the mail."

Credit: Washington Post

Hmm, now, where have I seen something similar to that?  Oh, yes: For millennials, a regular visit to the doctor’s office is not a primary concern.  That Washington Post article explained that: "Their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care."

Ateev Mehrotra, a professor at Harvard Medical School, told the Post: 

These trends are more evident among millennials, but not unique to them. I think people’s expectations have changed. Convenience [is prized] in almost every aspect of our lives,” from shopping to online banking.

See why I keep thinking about Sears?  

Walmart is trying to avoid a similar fate.  They've desperately tried to beef up their online capabilities, including purchasing such online-only merchants such as Jet,  Bonobos and Modcloth.  Walmart is trying to counter Amazon's purchase of Whole Foods by increasing its curb-side pickup and home delivery capabilities for groceries, seeing groceries as the biggest traffic driver to its stores.  It has historically done best with lower-income customers, but is trying to increase its appeal to more upscale shoppers.  

Sears would recognize that struggle.

The truth is that, while online shopping gets most of the publicity, the retail industry is still 90% offline.  Success still requires both physical and online presences. 

Analysis by Green Street Advisors

 Amazon is opening physical locations, and it is not the only online merchant to do so.  Jared Blank, of retail consulting firm Bluecore, told Bloomberg: "What some brands are starting to figure out is, ‘Oh wait, perhaps these retailers who have been around for 100 years were onto something."

Some of them, anyway.

Healthcare has the physical location part down.  You can't drive more than a couple miles in most communities without seeing a drugstore, an urgent care center, a medical office building, or even a hospital location.  Healthcare organizations are on a building craze that rivals anything mall developers have done (and many are moving into some of those malls).

Healthcare is also trying to beef up its online capabilities.  Telehealth is a boom industry, although actual use remains modest.  Patient portals have become the norm, but most patients still do not use them.   It's easy to buy many OTC health products online, but when it comes to healthcare services, it may be easy to find marketing information, but rare to actually be able to comparison shop or price them. 

If you want to DIY it, like those Sears kit houses used to let you do, the traditional healthcare industry isn't likely to be very happy about it. 

Healthcare now is sort of like shopping at Sears in the 1990's.  You could certainly find a store, and most likely could (eventually) find the product you wanted, but you might not be too sure it was a good buy.  If you wanted to shop online, well, Sears couldn't really help you but, hey, you could buy books on Amazon.   

It is not surprising that Walmart and Amazon both have designs on healthcare.  It is too big a market to ignore, and there is too much low-hanging fruit.  Marcus Osborn, Walmart's VP of health and wellness transformation, explicitly said their efforts in healthcare are because "none of us wants to be Sears." 

That should terrify healthcare executives, just as Sears executives should have been terrified when Walmart started expanding their physical presence or when Amazon started expanding from selling books.

What was that the Washington Post pointed out was lacking in healthcare?  Convenience, fast service, connectivity and price transparency.  Healthcare pays lip service to the need for more of these, but few parts of it are actually delivering on them.  Healthcare thinks it has time to figure out how to change, and prides itself that "health care is different."

It doesn't and it isn't. 

Life without Sears would have been unimaginable in the 1950's or 1960's.  As late as the 1980's it still seemed to be placing big bets for a continued future.  Yet within a few years it was struggling badly, and in 2018 it is bankrupt.  Omnipresence, name recognition, and even prior innovation do not guarantee continued success. 

Healthcare organizations: let Sears be a lesson for you.

Imagining the Future Us

One of the most thought-provoking articles I've read lately is Tom Vanderbilt's Why Futurism Has a Cultural Blindspot in Nautilus.   In it, he discusses how our technological visions of the future seem to do much better on predicting the technology of that future than they do the culture in which they will be used. 

As he says,

But when it comes to culture we tend to believe not that the future will be very different than the present day, but that it will be roughly the same. Try to imagine yourself at some future date....Chances are, that person resembles you now.

We need to keep this in mind when thinking about the future of healthcare: not just the nifty new technologies we'll have, but who and how we expect to use them. 

Credit: Ron Chapple/Getty Images

Mr. Vanderbilt quotes historian Judith Flanders: "Futurology is almost always wrong because it rarely takes into account behavioral changes.” She believes we look at the wrong things: “Transport to work, rather than the shape of work; technology itself, rather than how our behavior is changed by the very changes that technology brings.”

He cites a great example of a 1960's film about the office of the future that actually wasn't so far off in terms of the technology we'd be using, but it missed that there would be women in those offices.  Or, no doubt, that there would also be minorities, or that careers wouldn't be spent working for just one company, along with a nice pension at the end. 

Mr. Vanderbilt concludes: "It turns out that predicting who we will be is harder than predicting what we will be able to do."

All too often, especially in healthcare, we develop technology to solve incremental issues, not foundational ones.  All too often, especially in healthcare, we develop technology and then try to fit it into our existing culture, rather than imagining the culture we want and developing technologies to help achieve it.

It's not so hard to imagine how technology will change what health care is likely to look like in the not-so-distant future. 

• We'll be monitored 24/7, from our hearts to blood to our microbiome and more.  
• We'll get real-time feedback -- from A.I.s and humans -- on all that information so we can take appropriate actions.
• We'll always have our doctors available, in some form, and with all of our records available to them -- and us.
• We'll have much better information about what works for who when, making treatment options clearer and more evidence-based.
• We'll have ever more precise treatment options, from drugs with pinpoint accuracy to surgeries done at the cellular level by nanobots to modifying genes.
• We'll get most of our care done at home or close to home.     

The technological seeds for all of these are already here, and are already being used in some form.  The leaps to their widespread use are evolutionary ones, not revolutionary ones.  They won't be fully arrived by 2020, but will be well along by 2030 and certainly in place by 2050.  The specific details of their execution may surprise us but probably not the goals. 

But, like imagining that "office of the future" in the 1960's, what will the healthcare system in which they are used look like? 

Here are some open questions about the culture in which all these cool technologies will be used:

• Will we live in a culture that accepts health problems becoming financial disasters for some people?
• Will we live in a culture in which poor people can expect to get less care, to be less healthy, and to live less long?
• Will we live in a culture in which where you live dictates how well and how long you live, and the quality and quantity of care you receive?
• Will we live in a culture that treats social determinants of health and public health as secondary considerations?
• Will we live in a culture that treats health as primarily a medical concern, with too many people delegating responsibility for their health to their healthcare professionals and expecting some kind of medical interventions to deal with any health problems?
• Will we live in a culture that expects "treatment at any cost for any chance," especially for terminal issues?  
• Will we live in a culture that treats services like dental, vision, or "custodial" care as step-children?
• Will we live in a culture with an ever-growing array of medical experts -- M.D., D.O., D.C., Ph.D., D.P.M., PharmD, D.M.D., O.D., N.P., P.A.s, PTs, Au.D, to name a few (and not to mention sub-specialists)?  
• Will we live in a culture that treats medical expertise as primarily a local/state-level issue, rather than a national/international one?  

If the healthcare system of the future looks pretty much like the healthcare system of today, just with more and better tech, we will have failed.  And probably be broke. 

We need a different culture for health, and that culture needs new designs.  Marcus Engman, the former head of design for Ikea, told FastCompany: 

I want to show there’s an alternative to marketing, which is actually design.  And if you work with design and communications in the right way, that would be the best kind of marketing, without buying media.

I read that and I think "healthcare."  Healthcare does a lot of marketing, in many forms, but its ideas about design are more about aesthetics and revenues than about health or patients.  Substitute "health care" for "marketing" in Mr. Engman's quote and we start to get to what Steve Downs calls Building Health into the OS -- that is, designing to make health an integral part of our daily lives.  That's design.  That's a culture change.

Mr. Vanderbilt wonders why cultural change is so hard to predict, but speculates: "For one, we have long tended to forget that it does change. Status quo bias reigns."  Healthcare has gotten more expensive, and often more confusing and more impersonal.  We have many more options, but often less idea what to do about them.  These are not the cultural changes we wanted.

We have a culture of health care -- or, more accurately, of medical care -- rather than a culture of health.  Technology can exacerbate this, or help change it.  It's up to us to imagine the future in which we're most likely to be healthy.

Can You Hear Me Now?

Big news in DIY health.  Scratch that: big news in health, period.  The FDA just approved the Bose Hearing Aid, "the first hearing aid authorized for marketing by the FDA that enables users to fit, program and control the hearing aid on their own, without assistance from a health care provider." 

If that doesn't sound like big news, you must not have known anyone with a hearing aid.  Or you doesn't yet realize the broader implications of the approval.  DIY is coming for healthcare.

Credit: Audicos

Let's start with hearing aids.  Almost 40 million Americans report having trouble hearing, with the prevalence of hearing loss highest for those over 65.  As few as 20% of those with hearing loss actually get hearing aids, in no small part due to their cost. 

Traditional hearing aids are expensive.  Not hospital stay expensive, not immunosuppressive drug expensive, but typically several thousand dollars, and not usually covered by health insurance or Medicare.  There's a whole process of being tested by licensed audiologist, getting a prescription, being fitted, and, of course, often paying for it out of pocket. 

All that may change.  The FDA approved the Bose hearing aid under its De Novo premarket review pathway, which is "a regulatory pathway for some low- to moderate-risk devices that are novel and for which there is no prior legally marketed device."  The pathway was made possible by the 2017 Over the Counter Hearing Aid Act, aimed to make it easier for consumers with mid-to-moderate hearing loss to get hearing aids. 

The FDA reviewed data from 125 patients, comparing the outcomes of their self-fitting the Bose device to being professionally-fitted, and found them comparable; in fact, patients prefered their own settings over those done by the professionals. 

In most cases, consumers may still need to be tested by an audiologist and get a prescription from one.  Things will really heat up in 2020, when the FDA is expected to issue regulations that will allow consumers to bypass those steps. 

Stocks for leading hearing aid manufacturers took an immediate hit following the FDA announcement.  Bernstein analyst Lisa Bedell Clive wrote: 

In our view, how big of a threat the OTC channel will be to traditional hearing aid companies in part depends on the entrance of consumer electronics players, with their strong brands and significant marketing muscle.  It will be interesting to see if this is the first of a number of new entrants. For instance, we know Samsung has looked at hearing aids in the past.”

We've already seen a wave of Personal Sound Amplification Products (PSAPs) that can't be marketed as hearing aids but which attempt to solve the same problems, especially for those with only low or moderate hearing loss.  For example, Bose has its Hearphones and LifeEar offers CORE and BOOST. 

Think the Apple Watch is nifty, especially with its FDA-clearance for heart monitoring?  Wait for the Apple Earbud that serves as a hearing aid. 

We're already inching towards DIT audiology.  Audicus offers an online hearing test, which its in-house audiologists use to tailor hearing aids that are priced well below $1,000.  As founder and CEO Patrick Freuler told Crain's New York Business, "You can do everything from home with a few clicks of a button."  

Mr. Freuler plans to partner with pharmacies, offering the tests there, with the hearing aids available literally off-the-shelf.

Not surprisingly, the audiologists are not happy.  Audiologist Salvatore Gruttdauria told Crain's: "However, with a model like that, you're going to miss a lot of diseases and disorders that, No. 1, could possibly be treated and, No. 2, could have some serious medical consequences."  Mr. Freuler counters by noting that the vast majority of people who need hearing assistance never see an audiologist, much less get hearing aids, due to the time and trouble involved.  

Get used to those kinds of arguments.

Credit: Opernative

Lest you think this is all only about hearing, you can already take online vision tests, such as through Opernative or millennial favorite Warby Parker. 

As if those are not impressive enough, consider OpenAPS -- the open source artificial pancreas system.  Launched in 2015, it helps people build their own systems to communicate between insulin pumps and glucose monitors.  The systems are not approved by the FDA.

Reuters reports 725 people using such a system, and that the system "appears to improve outcomes among people with type 1 diabetes."  Dr. Michelle L. Litchman, of the College of Nursing at the University of Utah, told Reuters: 

People with diabetes and their caregivers (ie, parents) are crowdsourcing solutions to enhance diabetes technology because they perceive industry and FDA have not met their immediate needs.  Although unconventional, OpenAPS is forcing conversations around the speed in which diabetes technology is developed and approved."

Dr. Norman Waugh from Warwick Medical School (UK) had some advice for physicians and others who were resistant to the movement: "Support it and be prepared to learn from the OpenAPS people."  

Dr. Joyce Lee -- Doctor as Designer -- sees a broader trend, telling Reuters: 

The DIY artificial pancreas could be considered a novel example of personalized medicine.  We are only going to see more examples of this in an era of patient autonomy, mobile computing, and peer-to-peer learning through social media.

Heck, there are even attempts at DIY dentistry, such as through SmileDirectClub or Australia's EZ Smile.

MIT thinks enough of the DIY movement to sponsor the Little Devices Lab.  It's mission:

We develop empowerment technologies for health. We believe that innovation and design happens at the frontline of healthcare where providers and patients can invent everyday technologies to improve outcomes. By radically democratizing the tools of medical creation, we seek to enable front line patients and providers to invent answers to disease burdens.

I especially love the "radically democratizing the tools of medical creation."

Ampli diagnostic blocks, credit: MIT Little Devices Lab

This is cool stuff.  This is scary stuff.  This is what happens when the traditional healthcare processes produce results that take too long, are too expensive, and/or are not easy for consumers/people/patients to use.  Some of these efforts will fail.  Some may harm some users. 

Some, though, may show that what we have traditionally done is not enough in the 21st century; just wait until 3D printing becomes cheap and readily accessible. 

Can you hear -- or see -- what's coming?

Breaking Healthcare's "Monoculture of Thought"

I read a phrase recently that I can't get out of my head: "monoculture of thought."  It wasn't said about healthcare, nor was it said by someone in healthcare, but I keep thinking it is a pretty good description of healthcare.

Image: Steve Lipofsky

The quote comes from Jessica Powell, in an interview with Farhad Manjoo for The New York Times.   Ms. Powell is a former Google executive who has written a novel that is a not-so-thinly-disguised portrait of life in Silicon Valley, where, as Mr. Manjoo puts it: "A lack of diversity is not just one of several issues for Silicon Valley to fix, but is instead the keystone problem."

Or, as Ms.Powell told him: "It’s a monoculture of thought, and that’s a real problem."

Lack of diversity has also been identified as an issue for healthcare, although it has usually been focused on the fact that, historically, most physicians were men.  That continues to be true, with women only making up about a third of active physicians (although women make up almost half of medical school graduates).  It has not only been a man's profession, it's been a white man's profession, with African-Americans and Hispanics still underrepresented.   
  
We've also come to realize that health and healthcare are not blind: clinical trials need more diversity, women's health is often shortchanged,  and we have deep-rooted racial and ethnic disparities.   

All of those are real problems for healthcare, and must be addressed, but, like Ms. Powell, I want to talk about the monoculture of thought.

We don't think much of our healthcare system, and for good reason.  It costs too much, it leaves too many people without access to care and/or financial protection, too much of what is done is of questionable value, and we don't end up any healthier or living longer than those in other countries.  

Despite all that, we want more of the same.  We want more physicians, more hospitals, more drugs, more health insurance, and plenty more technology.  We want what we have now, just better somehow.  We've fallen prey to healthcare's Stockholm Syndrome. 

That's healthcare's monoculture of thought problem.  

Here are some examples:

1.  We think we know how to educate physicians:  A new study found that there is no correlation between how highly regarded physicians' medical schools are and their patients' outcomes.  It takes longer to get trained as a physician in the U.S. than in many other countries, without a clear positive impact on patients of those extra years.  Heck, after over a hundred years we still can't decide between allopathic and osteopathic medicine.  

We can't even agree on how to do ongoing certification of physicians.  

2.  We think physicians always use best practices: We like to think that physicians base their treatments based on the best available evidence, right?  In fact, too often physicians base their clinical decisions based on how they were trained, where they practice, and what they've always done -- even when the evidence would suggest different decisions.  

The Dartmouth Atlas has been preaching this for decades, and organizations like the Lown Institute, Choosing Wisely, and The NNT Group have echoed the need for evidence-based medicine, with little discernible impact.

Source: Bipartisan Policy Center

3. We think health care brings health: See the doctor.  Get a prescription.  Have those screenings.   Go through that test or procedure.  Use the ER.  In short, we think that the healthcare system is the answer to our health.  That is wrong.  We spend most of our health dollar on health care, but most of what impacts our health happens outside the healthcare system.  

A small percent of us need a lot of healthcare, and cost a lot of money, but most of us don't, and our health investments might be better spent elsewhere.

4.  We think patient data belongs to everyone but the patient.  We've been talking about the value of sharing patient data for decades, and significantly moved the needle on how much of that data is digital, but we're still struggling with interoperability of patient data.  

Too much of patient data is trapped within physician practices, within health systems, and/or within EHR vendors.  Too much of the data is supposedly "de-identified" and then sold to third parties, without getting patient consent, ensuring true anonymity, or including patients in its economic value.   What should be an asset of the patient ends up being an asset for everyone else.  

5.  We think technology will be the solution to our problems.  We wanted electronic records; we got them, to no one's delight.  We wanted m-health/e-health/digital health, and we're getting it, but with all that connectivity and all that new data, we're not sure what is useful, how we'll use it, or whether it will result in making us healthier -- or just more worried.  We see the future value of genomics, but our ability to test is far outpacing our ability to understand, much less use, the information we can gather.  

Technology will be a crucial part of healthcare's future, but it will support the reforms we need, not bring them about.  We need to start with better understanding of what makes us healthy and how to motivate us towards the right behaviors.  We need to more rigorously track what "works," and who makes it work best.  And we need to revamp how and what we finance.     

None of these problems are unknown.  None are being ignored.  But way too little progress is being made on any of them. 
  

There is a well-known expression: "if your only tool is a hammer, then every problem looks like a nail."  Healthcare has a lot of people with a lot of hammers, only they're stethoscopes, scalpels, MRIs, chemotherapies, and the like.  They're buildings and offices that need to get filled.  Too many health problems are seen as nails, needing those medical hammers.    

That's the monoculture of thought in healthcare. 

Most healthcare experts scoff at the various outsiders who are showing interest in healthcare.  It's too complicated, it's too unique, they warn.  Maybe.  But I'm increasingly of the belief that it is only from outside of healthcare that we'll get the new ideas and the new approaches that healthcare needs -- and that those ideas and those approaches won't look like or easily fit in with what we have now.   

Want to bet on which monoculture of thought changes first -- Silicon Valley or healthcare?