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PCAST and Clarke’s Third Law

by Wes Rishel  |  December 21, 2010  |  1 Comment

Arthur C. Clarke’s third Law of Prediction is, “any sufficiently advanced technology is indistinguishable from magic.”

I submit the converse of Clarke’s third Law is also true, “any magic is indistinguishable from sufficiently advanced technology.” That is, visionary ideas that seem like magical thinking may well end up being correct given future advances in technology.

Much of the PCAST Report represents a canny understanding of the ability of the Internet to facilitate disruptive innovation. This is the Christensen gospel (pun intended) that was originally described as disruptive technologies. The well-established insight is that simpler technologies can support the “bottom 80%” of the market when dominant vendors have driven complexity and price towards the high end.

I favor innovation and, in a small way have worked to promote disruption. I hope that the government continues to work to remove barriers to innovation. At the same time, however, I haven’t seen Christensen or anyone else describe how a government or anyone else can conceive a sure bet on disruptive technology. As with all innovative and entrepreneurial approaches if the advance were so obvious that everyone agreed it wouldn’t be disruptive. As my mentor Don Simborg used to say, “the difference between an entrepreneur and a paranoid schizophrenic is customers.” According to Christensen disruption often is not immediate or short term. The transition has taken 20-30 years in some industries.

ONC and CMS are faced with some tough decisions between changing course and putting going all-in on disruptive technology or continuing to issue regulations that have the effect of inhibiting innovation. We have one example of their handling of this dilemma to date, they chose to enable a simpler technology (The Direct Project) without canceling a more complex technology (CONNECT). They also chose not write either into regulations until they had some evidence. “Evidence based regulation” sounds like a worthy concept.

The agencies must also walk the line between being a disenabler of innovation and reversing current approaches which are in fact achieving some growth in EHR usage. I hope to raise several ideas that have been stimulated by reading the report and address them in my blog from the point of view of what evidence is available or could be found. Here are the first two.

Should the agencies require cloud implementations and “modern” technology? We must consider that all of the examples the report cited of realization of true value from EHRs comes from technologies that technology firm generally deride as antiquated. Should the government enable (i.e., not disable) products supplied through cloud technology? It already does.

Should the agencies adjust their meaningful use requirements to reduce the total investment for a start up vendor and enable simpler products that might be more palatable to physicians? This may be the most challenging part of the report. Meaningful use was conceived by Congress as a way of ensuring the stewardship for the incentive funds. Is it better to set stretch goals and make that the challenge for innovators? When the potential outlay is this large it would be dumb (and unacceptable to taxpayers) to say “here’s a bunch of money, do something good with it, you decide.” Should it tweak the goals to allow a more fertile ground for simpler (and potentially disruptive) products? Remember, there is no proof of a specific innovative approach waiting in the wings and while small practices may not adopt EHRs as much as is hoped, current roll-out is happening. ONC and CMS have two chances to evaluate this question as they set regulations for 2013 and 2015. They have firmly said they will wait to judge early acceptance. I believe that they should use the lessons of 2011 in setting a course for reduced requirements. At the same time, to the extent that it has grant opportunities or other ways of turning the potential of simpler approaches into something tangible that can be evaluated as an alternative, that can only help.

Category: healthcare-providers  interoperability  

Tags: ehr  health-information-exchange  healthcare-interoperability  meaningful-use  nhin  nhin-direct  pcast-report  

Thoughts on PCAST and Clarke’s Third Law

  1. Brian Ahier says:

    “Evidence based regulation” ~ what a concept! Thanks for your service and spectacular insights. You raise some especially salient points.

    One aspect of the report that bears on the issue of EHR adoption is the network effect. The nationwide health information network becomes more valuable as more providers get on board. I favor the simpler Direct Project approach to enable the little guy to participate, and using policy levers to continue to drive greater exchange capabilities. As more providers join in, the network becomes more attractive and we could see some rapid scaling.

    After listening to your HITSC meeting last week I have no doubt that the health information exchange components of the standards and certification criteria for stage 2 meaningful use will be more robust than initially thought.

    But I have always thought that capturing the data was only a tiny first step, but the real value comes from the ability to exchange. Simply moving from disparate systems of dead tree medical records to disparate systems of digital records will not get us any closer to the goals of improving the quality of care and lowering costs. We need a standard mechanism to exchange health data, and interstate exchange, with all the spaghetti strands of various consent laws and privacy regulations, is going to be a tough nut to crack.

    But let’s not forget the political and economic realities in which we live. It is unlikely that there will be additional funding sources and the regulatory environment may shift as well. It would be wise to try and accomplish as much as possible within the existing policy framework…

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