Eric Morris, pursuing a PhD in Transportation at UCLA in 2007 wrote an article entitled From Horse Power to Horsepower. It is well worth reading through the lens of someone interested in health care reform and innovation.
Morris briefly relates the story of an urban planning crisis in the late 19th century -- the explosive growth of the urban horse. The parallels between the plight of the Industrial Age city planners, and the Information Age healthcare planners are remarkable.
Cities at the turn of the century were in the midst of an equine perfect storm. The urban population was skyrocketing. As the population increased, so did the country's economic prosperity. Growth in per capita income allowed more people to have access to a horse. The explosion of inter-city rail transport increased the need for horses, to move goods from the train terminals to consumers.
You can almost hear the cries of non-sustainability. The feed to maintain one horse required five acres of farm land. A landmass the size of West Virginia would be necessary to support the horse population at its peak. Waste was a major concern, and there were dire predictions of city streets buried in several feet of manure. In fact, manure did fill vacant lots in piles up to six stories high. A horse drawn vehicle neither accelerates nor decelerates quickly. As a consequence, traffic was snarled, particularly at intersections. Paradoxically, traffic fatalities were actually higher than in the age of the automobile (imagine if your Hyundai could be startled by an unexpected noise, and bolt of its own volition).
Enter the Incremental Innovators.
Large stagecoaches, or omnibuses, enabled more people to travel with fewer horses. However, a large omnibus still required eleven horses per day to operate. Rails were laid in city streets, decreasing friction and cutting in half the number of necessary horses. Stop signs and yield signs were innovations of the age of the urban horse. A cadre of crosswalk sweepers were employed to maintain manure-free street crossings for pedestrians.
It is obvious to all what ultimately solved the crisis was not the Incremental Innovators, but the Disruptive Innovators. The internal combustion engine was perfected. Streets were paved with asphalt. Henry Ford introduced principles of mass production and the assembly line, dramatically bringing down costs and democratizing automotive technology.
There are some lessons to be drawn from the transition from horse to car.
Once the disruptive innovation hit, it hit with a vengeance. The pace of change was dizzying. In 1900 there were 8000 cars registered in the United States. By 1915, that number had ballooned to over 2.5 million (United States Department of Transportation).
The sudden transformation was unexpected. It is unlikely the public servants of the day, concerning themselves with waste removal and grain transport challenges, ever envisioned the transformational impact of the automobile. What is this disruptive innovation today? What game-changing technology, treatment, system of care or societal disruption will make our current menu of challenges seem quaint? On the other hand, what are we innovating around today that is merely extending the life of the old system? Today our industry is contemplating fundamental changes to the doctor physician interaction -- virtual visits -- group physician visits -- primary care clinics in retail shopping chains. Do these constitute disruptive change, or are they the street sweepers of the early 1900's, working to accommodate a failing infrastructure? The disruption will come, and when it does I suspect the speed of change and adoption in 2012 will be swifter than in 1912.
The automobile was made widely available, even to those of limited means. The technology grew from novelty to luxury to necessity in a generation. It is likely our "automobile analog" will be in some way related to the wide spread availability of inexpensive high-speed broadband access. Rapid communication and data transfer is already fundamentally changing almost every facet of our life. Healthcare will be no different.
The disruptive innovation may spring from any number of directions. For anyone interested in healthcare innovation, Eric Topol's The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care should be required reading. Well organized and written to be accessible to the lay reader, Dr. Topol covers in detail the wide range of changes in health, driven by access to information, remote monitoring and care tools, the growth in practical importance of the human genome (democratization?), big data and more. Perhaps one of these is the seed that will produce automobile-like disruption of healthcare.
(Note: I learned of the Eric Morris article referenced above in a casual conversation. I was unable to find a source drawing an analogy to healthcare. If you are aware of a reference, please let me know so I may credit it appropriately).
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