On December 16, 2010, in Acceleration

Accelerating change is the central theme of the Digest, and in this issue we see how pundits have recently assessed change from (1) a global perspective, (2) an IT perspective, (3) a sophisticated healthcare perspective, (4) a simple technologies perspective, (5) a hospital/medical perspective, and (6) a seldom-mentioned perspective of the patient of the future.

1. Crucibles of Change

“In our experience,” wrote a group of analysts at McKinsey, “if senior executives wait for the full impact of global forces to manifest themselves at an industry and company level, they will have waited too long.” Their report identified five “crucibles of change” that “will restructure the world economy for the foreseeable future.”

Drastically summarized and liberally interpreted by me, the “crucibles of change” are:

  1. Economic growth in developing countries, which will be accompanied by rising consumption, growth of a middle class, and “profound innovations in product design, market infrastructure, and value chains” in the developing world.
  1. Economic growth in the developed countries, which can only be achieved through greater productivity.
  1. Innovation, whose acceleration (the result of more sophisticated global networking) will result in “destabilizing cycles of volatility.”
  1. The environment, which will benefit from “Increased focus on resource productivity, the emergence of substantial clean-tech industries, and regulatory initiatives.”
  1. Global governance, which will increasingly clash with national governance.

The forces operating in these crucibles will lead, the analysts think, to economic crises, forcing “thousands upon thousands of companies [to] make it up as they go.” Their conclusion: “Even the most talented strategists will have, at best, incomplete knowledge of what comes next. But from our experience, we know that an understanding of the forces defining the future will also provide the best chance for seizing it.” (As our new tagline for the Digest puts it: “When it comes to the future, no news is bad news.”)

A sensible conclusion, but they have not followed the forces they identified to their logical conclusions, which (it seems to us) are: That the differential in the forces of economic growth, innovation, and productivity as between the developed and developing world will lead to global wages equilibrium and to the eventual replacement of workers by machines.

When you can see these forces starting to produce the predicted results (as you can, today, in global economic and employment statistics) then alarming questions arise, such as: For whom will the machines produce, if there are no wage-earners with enough cash to consume their output? How will an ex-burger flipper be able to afford to buy a burger, or an ex-surgeon an operation, or an ex-Toyota worker a car, from the robots that took their jobs? Like issues of finance and currency, these are global questions, and satisfactory solutions can only emerge through global governance.

The Jobless Economy

You can see the forces starting to bite in the growing number of long-term unemployed, and in a government program that would keep them that way. Starbucks’ decision to provide free wifi to anyone in its coffee shops was seen by one reporter as a recognition that the unemployed are here to stay and comprise a market substantial enough to be worth marketing to. The US Defense Advanced Research Projects Agency (DARPA) is initiating projects which, if successful, will result in highly automated generic factories whose robot workers will able to build anything that can be designed on a computer, while unemployed factory workers cry into their coffee. When you consider the advanced state of automation in some factories today, you realize that DARPA’s goals are neither far-fetched nor far from fruition.

Failure to acknowledge and anticipate large-scale, permanent, un- and under-employment will be the biggest single cause of global economic, social, and political mayhem within the next two decades, we predict, as does economist Jeremy Rifkin, who has been warning of the end of work for nearly two decades. In his recent book The Empathic Civilization, Rifkin sees an increasingly “shattered” global economy and “a massive loss of social trust in economic and political institutions.” Once again, we can see the signs of this in the persistence of the 2008 recession, and in the leaves of the Tea Party.

It’s not just companies that will have to make it up as they go. It’s everyone.

2. Ten IT-driven Transformations

Another ten trends, this time IT-driven and directly affecting the organization rather than civilization, result from “the combined effects of emerging Internet technologies, increased computing power, and fast, pervasive digital communications.” The trends, again as we interpret and summarize them, are these:

  1. More products and services will be developed, marketed, and supported solely over the Web.
  1. Network and organization will be integrated to the point of synonymy, with all that implies for horizontal integration, flexibility, just-in-time staffing, and more responsive control structures.
  1. The use of collaboration technologies, such as videoconferencing and social networking tools, will explode.
  1. An emerging “Internet of Things”—self-aware, intelligent, inter-communicating devices—will result in more efficiency and more automation of processes, new product capabilities, and new business models. (As an example in medicine, they cite “sensors embedded in or worn by patients [that] continuously report changes in health conditions to physicians, who can adjust treatments when necessary.”)
  1. Advanced analytics will be applied to the deluge of data from the Internet of people and things, supporting “constant business experimentation,” executive decision-making, and new product/service development and testing.
  1. IT energy use, recycling, and resulting environmental impact will decrease, while the application of IT to reduce energy use across enterprises will increase.
  1. Services will replace products, in the way that “cloud” apps replace client/server and desktop software and hardware products. Customers will buy units of a service and account for them as a variable cost requiring little capital, rather than as a capital cost. This is an extremely disruptive innovation.
  1. A “multisided” business model is emerging whereby companies give away apps—from email to sophisticated IT-management apps to Sermo, an online community for physician networking—and make money by selling audience data to advertisers and other businesses. Every business should ask “What would happen if we—or our competitors—provided our product or service free of charge?”
  1. Growing innovation in “microbanking” in the developing world will spread to the developed world and have global impact.
  1. Technology applied to the public infrastructure and to public policy will improve government efficiency and effectiveness.

These trends, say the authors, will accelerate, but that does not mean they will be easy. Organizations must adapt their structures, cultures, skill sets, and technologies if they are to be participants in, rather than victims of, the trends.

3. Ten More Transformers

The Harvard Business Review honed down the innovations that could have a transformative impact on medical organizations in particular to these ten:

  1. Checklists before surgery or inserting central lines into patients. There’s unassailable evidence that checklists improve quality and safety, yet the adoption rate is slow.
  1. Behavioral economics tools that nudge patients and caregivers to behave in desired ways; for example, “reminders, social pressure, default options, rewards, and other behavioral tricks” to improve compliance in stroke and diabetes patients. (We would note that many of these tools are available through cellphone apps.)
  1. Patient portals—or what have become to be known as personal health records (PHRs) such as Microsoft HealthVault and Google Health.
  1. Payment innovations—anything that gets us away from the “badly broken” fee-for-service payment model.
  1. Evidence-based decision support for clinicians, based on real-time EMR data mining.
  1. Accountable Care Organizations (ACOs) that incentivize doctors and hospitals to keep people healthy and out of the hospital, and idea that “seems both brilliant and obvious.”
  1. Virtual visits to the doctor’s office through videoconferencing. The convenience, low cost, and potential to enrich doctor-patient relationships is hamstrung by current rules and cultural barriers.
  1. Regenerative medicine, especially stem cell therapies. “There’s every reason to be optimistic about the prospects for stem cell therapy, but the devil is in the details.”
  1. Robotic surgeries “will become increasingly common (and expected) in ORs, although “it may be years before we know how well they work.”
  1. Genetic medicine to replace defective genes with working ones and to tailor drug treatment to a patient’s specific genetic profile shows increasing promise after some false starts. “The question is when, not if, genetic medicine will become routine.”

4. Some Simple Transformers

Some of Harvard’s ten innovations are currently rare and complex. Fellow health futurist Joe Flower thinks, on the other hand, that greater transformation will come through the commonplace: cellphones and the Web. It won’t come through health reform, whose success is far off and far from guaranteed, nor from “shiny big” technologies such as “robotics, blockbuster drugs and the latest scanners.”

Flower points out that cellphones “are emerging not only as information distributors, but as clinical management tools” as well as public health management and patient self-management tools. Today’s apps include clinical workflow systems and checklists, formularies, access to EMRs and PACS, remote public health data collection, remote monitoring, communication with workers in the field, tracking epidemics, and remote diagnostics and treatment.

Tomorrow’s technologies will include inexpensive microscopes that snap onto a cellphone’s camera a sonogram device that snaps into a smartphone’s USB port and delivers the image to the phone’s screen, and an oximeter. These, says Flower, are disruptive technologies that “tend to route around the existing medical infrastructure and value chain, linking up in alternative value chains and business models.”

What he calls “apomediaries” have a similar impact. They are social-media-like websites that deliver expertise (whether from clinicians or more or less informed patients) direct to the patient, and in some cases delivering decision support to doctors themselves.

The transformative tide of these technologies, he says, “is turning to flood.”

5. Hospital Service Line Transformations

Even so, inside the hospital, other transformative innovations are at work. In the first decade of the new millennium, hospital service lines have been transformed and will continue to be transformed over the next decade, according to a (members-only) paper from the Advisory Board, as follows:

Cardiovascular services

Drug-eluting stents and the cath lab have largely replaced CABG and the OR as the epicenter of an earthquake that has reshaped cardiovascular medicine over the past decade. Vascular medicine was a distinct field but is now almost fully integrated with cardiovascular care.

In the coming decade, percutaneous valves will shift even more procedures from the OR to the cath lab, threatening surgeons who have been “using valve surgery to backfill their lost CABG volumes,” but also giving them a way to stay relevant and in business, as carotid stenting and AAA stents did for vascular surgeons. Expect “paradigm shifts in surgeon training and OR design (like the hybrid OR)” over the coming decade.

But the earthquake could be even more powerful, and the paradigm shift even more radical:  Personalized genomic and regenerative medicine could bring “an altogether new generation of [cardiovascular] care delivery” in the 2010s.


At the start of the decade, 4-slice and 8-slice CT scanners were the norm. Today, 64-slicers are everywhere and dual-source, 256-slice, and 320-slice CTs are on the market. There has been “explosive” growth in MRI availability and volume, though the 1.5T available at the beginning was still the standard of care at the end, with high-field open, wide-bore, and 3T scanners making rapid ground. Other modalities, especially breast imaging, nuclear imaging, and ultrasound, have also seen explosive growth. 64-slice CT set the stage for coronary CT angiography (CCTA) but logistical issues—not technology—continue to impede the development of strong CCTA programs.

In the next decade, diagnostic imaging (especially the radiation-free modalities) will increasingly be used in population-level screening and diagnostics. To today’s mammography will be added screening for heart disease, colorectal cancer, and breast cancer using advanced diagnostic imaging modalities to catch disease earlier. Molecular imaging using MRI, PET/CT, and SPECT/CT, plus advances in radiotracers and isotopes for molecular imaging studies, will spur greater movement toward personalized diagnoses and treatment decisions, though the movement will be retarded by the lengthy and costly regulatory process.


Over the past decade, neurointerventional and neurostimulation devices emerged as alternative methods of treatment to patients who failed traditional, medicine-based, therapies. Comprehensive stroke centers, epilepsy monitoring units, and sleep centers with multidisciplinary care teams all appeared. The MERCI Clot Retriever, approved in 2004, was used in 10,000 patients nationwide and transformed the way that hospitals deal with stroke patients and with one another.

Over the next decade, regional stroke networks will proliferate, and telemedicine will be used more commonly as a tool for expanding patient access to neurologists, neurointerventionalists, and psychiatrists. Advanced imaging techniques will help provide more tailored treatment for patients. There will be more development of brain-computer interfaces for assisting, augmenting, or repairing human cognition and sensory-motor functions.


In the past decade, major but incremental advances were made in radiation, medical, and surgical oncology. The potentially transformative standout was interventional oncology, a minimally invasive approach using thermal or electric energy, targeted delivery of chemotherapy, or targeted delivery of radioactive agents.

Orthopedics and Spine

This has been the decade of the “premium implant”—ceramic hips, gender-specific knees, etc. Spine also transitioned from an “era of fusion” to an “era of motion preservation.” A flood of new devices promised better motion and durability, though at a high price and with little evidence so far of superiority over standard implants. Better customization of the device to the patient and a reduction in implant alignment errors, which could be achieved by using surgical robots, would be transformative, but the cost of robots alone will mean slow progress over the next decade.


The past decade saw a growing shortage of pediatric specialists and subspecialists, and a shift towards minimally invasive pediatric surgery. In the coming decade, the medical home model will be applied to manage children with chronic conditions and in general, for improving the continuity of care.


In the past decade, the use of minimally invasive and robotic surgeries has grown rapidly, and bariatric surgery improved markedly. In the next decade, expect more of the same, especially bariatric surgeries to tackle the diabetes epidemic, plus potentially the spread of NOTES (surgery through the body’s natural orifices.)

Women’s services

In the past decade, uterine fibroid embolization grew in popularity, as did Essure, a non-surgical sterilization device that makes permanent birth control possible for women who do not want to undergo tubal ligation or hysterectomy. Advances in the treatment of urogynecological conditions have also been “extremely significant.”

6. Patient Transformation

So far, we’ve looked at change from a global perspective on down through a hospital service line perspective. We thought we’d leave you with a perspective that encompasses transformation both at the societal level and at the individual level. It is a perspective on the future patient, that generally goes unnoticed in the glare of more immediate (but not by much) concerns about the baby boomer patient explosion.

“Smart phones, MP3 players, laptops and other devices are the air kids breathe — perhaps too deeply,” said an AP article last January. The comment was based on a Kaiser Family Foundation study which found that children between ages 8 to 18 devoted an average of seven hours and 38 minutes a day consuming some form of media. Study co-author Donald Roberts called the finding “a game changer” and said “We’re really close to kids being online 24/7.”

This has all sorts of implications, such as for education and for the health of sedentary children, but here we just wish to point out that social networks are where hospital marketers increasingly must go to find new customers and connect with existing ones. (Joe Flower would surely agree.)  Unfortunately, that may come at some cost to social values. Danah Boyd, a social media researcher at Microsoft, has called upon the social media to take more responsibility for how they handle users’ personal information, according to an article in Technology Review. Boyd claims that Facebook users, for example, just don’t realize there is a mismatch between the privacy they think they have and the privacy Facebook actually affords them.

Social media companies make more money by confusing their users, thereby gathering more personal data to sell to advertisers. According to Boyd, the social media say that only “old fuddy-duddies” are concerned about privacy, and that social norms about privacy have changed. “Part of that is strategic. Law follows social norms.” That corporations would seek, for profit, to manipulate a gullible, young, and unsophisticated society out of social values honed and handed down through countless generations is deeply disturbing to us old fuddy-duddies.

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Key takeaways from this issue: Change is accelerating everywhere and at all levels. The change is transformative, not merely incremental (some might say revolutionary, not evolutionary.) Awareness of the transformative trends gives you a chance to prepare for them, adapt to them, and benefit from them, rather than be overwhelmed by them. When it comes to the future, no news is bad news.

Time saved this issue: Original words: 19,883. Digest: 2,827 (14 percent). Assuming approx. 5 minutes to read 1,000 words: Originals: 1 hour 40 minutes. This Digest: 15 minutes. Time saved: 1 hour 25 minutes.


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