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Graph of the locations of water on EarthI attended the European Foundation for Management Development conference at Advancia 22-23 February 2010, to meet new colleagues as well as participate in a panel discussion on the challenges facing entrepreneurs. I organised my presentation around the question: “what sort of the future will the entrepreneur invent?”  I used two pictures to start my talk, one a 1530 Utopian painting and the other a poster of Fritz Lang’s dystopian film Metropolis.

Everything around us is invented, discovered, or created by the mind of people making sense of the world, so while it may be too much to see the entrepreneur as a super-human force of nature (as some discussed at the conference), the point is that human ingenuity is behind the world we live in, and our ability to be ingenious drives the

entrepreneurial spirit. I raised these issues in my presentation:

  • crises are really opportunities, especially for entrepreneurs;
  • the growing networking and interconnectedness of the world offers amazing opportunities for entrepreneurs to look at ways to bring people, information and services together; concerns about digital divides, social exclusion etc., in my view are transitional features of the current world, and not defining features, and that in time, these will be replaced with other forms of exclusion; the point being that technologies themselves are not exclusionary, but what people do with them is;
  • rising educational attainment is upon us, and there will be a substantial decline in the percentageof the population globally with only primary education, and doubling in the next decade or so of numbers of people with tertiary education; again, this offers amazing opportunities for learning in new ways, also considering the networking of the planet;
  • agricultural innovation is seriously important as over the next 20 or so growing seasons (years), the planet’s population will rise by about 30%, per capita food consumption will rise by 50%, dietary preferences will change, water and energy demand will also rise; this points to the need to ensure that fresh water is where the people are (right now, the fresh water is located mostly where people are fewer), and that each agriculturally productive hectare can add 50% of productive capacity — in very few growing seasons; with climate change, too, factors such as what grows where comes under stress, as different areas will need to learn to grow non-traditional crops, and other areas will become unproductive;
  • I also showed pictures of intelligent machines such as an autonomous GPS-guided farm tractor, and a similarly autonomous mining truck; the autonomous military robot with its gun on top is a telling reminder of the progress in military science, while the Utopian picture of the smart city of the future offers a different sort of hope;
  • finally, I showed a map of the world 4 degrees warmer, and wondered how we were going to deal with social displacement indicated by the growing numbers of people who will come to live in unihabitable or hostile environments (at risk of flooding, heat stress, and so on).

Having said all that, I am left to wondering though how we bridge the entrepreneurial challenges facing the public sector.  In many cases the challenges entrepreneurs face are caused by governments, and by regulation, as well as by restrictive banking practices which make access to capital so very hard. While we look to the entrepreneurial spirit in the private sector, and feed and encourage creativity, we find the opposite is true in the public sector. Indeed, Martin Lukes, from Prague, presented an excellent paper, with a telling conclusion that public sector people have less organisational support for innovation and entrepreneurial activity than their private sector counterparts. In some respects the elephant in the room is the public sector, consuming huge amounts of taxpayers’ money, yet often failing in two ways, failing to ensure entrepreneurial growth through poorly thought out rules and regulations (red-tape, regulatory burden and so on), and failing to get their own house in order.  Given the current state of affairs in some the world’s major economies, I don’t think the public sector can excuse itself from the need for entrepreneurial reform and effort.

The invention of the future requires all hands on deck, and no one can be spectator any more.

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The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Hospital Universitario Marqués de Valdecilla, ...
Hospital Complex, Spain

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

  1. their capabilities and
  2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.

A swarm of robots in the Open-source micro-rob...
Robot Swarm: planning a revolution?

We have had years of reform efforts in healthcare, and despite what country one picks, the themes are depressingly familiar: cost-containment, more health professionals, patient empowerment, more primary care, value for money, and so on.  These types of reforms are rarely revolutionary, despite the claims, and the benefits not as readily forthcoming as forecast. For instance, we have had perhaps 20 years of integrated care pathways, yet such simple knitting together of care is still elusive.  What is clear, though, is that you can’t continue to spend good taxpayers’ money on unreformed health systems.

Reform models reflect the history of our healthcare (and other) systems, deriving from organisational and service delivery models of the industrial age.  Hospitals are really just 1030s conglomerates, and the claims that vertical integration likely to improve care and drive down costs, are simply copying the corporate models of General Motors, General Electric, GEC, Westinghouse, some of which are no more.  We don’t really live in that sort of world anymore, and despite the vast amount of money spent on healthcare, it is still the least information-enabled of all sectors of our economy, even though healthcare floats on an ever-changing sea of knowledge and clinical/patient information.  Our current notion of healthcare is wedded to the brains of individuals (i.e. health professionals), not the collective intelligence of many people working together (dare I call this cloud cognition, hive minds, or distributed cognitive systems…?).

I think we need to take a different look at reform models, and embrace a new terminology, one built on disruption.  Disruptive technologies in particular are game-changing, they alter our modes of interaction with other people, change how we manage information, make decisions, perhaps even think. They, of course, produce winners and losers, as these sorts of changes often are zero-sum. Keep in mind that health reform has tended to be non-zero-sum; there has been a fear of creating losers while at the same time trying to reward winners, so-called protection of legacy providers, and we see this in the most recent UK Department of Health plans to allow failing NHS providers two tries to improve performance before alternative providers will be allowed to take over the work. Disruption says enough is enough, and we must do things differently.

We don’t know that much about disruption except by what its effect is on us, but there are efforts to understand  disruption.  But this work has been weakly connected to both the policy space in which these insights can achieve some measure of meaning, and the real-world.  Healthcare systems can go to great lengths to frustrate innovation and change.  It is, therefore, timely and pleasing to see efforts of understand disruption, and the forthcoming report on disruptive forecasting from the US Committee on Forecasting Disruptive Technologies, National Research Council, may offer a renewed impetus not just to the forecasting work, but to its utility.

I like disruptive technologies for their ability to shift our thinking away from industrial age paradigms to information age paradigms.  In this way, we break the logic of physicality that defines, for instance, hospitals, and leads to new approaches anchored around the health information value chain, which unites patients and all actors in health systems (payers, providers, industry, academe).  Ehealth is one of these potentially disruptive technologies, as it achieves a couple of key disruptions, in terms of decoupling patients from physical location, and of the potential pooling of knowledge in distributed cognitive systems with machine intelligences through smart/remote diagnostics, predictive modelling and in time physical models of disease.

But disruptions are a much harder sell, but it seems to me that difficult public finances does offer an opportunity for rethinking: one should not waste a perfectly good crisis as it is an opportunity to evolve. (with apologies to Rahm Emanual who said “never waste a good crisis”.

READ an interview I gave on ehealth here: [LINK to Euractiv ehealth interview]

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A small village clinic in Veliky Vrag, Nizhny ...
Hospital of the future?

Central to all healthcare systems is the notion of the hospital.  Are these remnants of industrial-age or can they be rethought and refreshed for the post-industrial and information world we are likely to inhabit for some time?  Foucault spoke of the birth of the clinic (hospital); I will write about its demise.

The logic of hospitals has a lot to do with aggregation of technologies and brains.  It is easier to move the patient to the hospital where integrated systems kick in and provide care, than to have all that expertise go to the patient.  That paradigm is getting tired, but yet our thinking is still hospital-oriented.  What is the way out?

Evolution of artificial intelligence systems, for instance, points to the possibility of remote locations having access to clinical brains, either embedded in portable diagnostic technologies, or through distributed intelligent systems, or even more mundanely at the end of a telephone.  Perhaps it will take time to be comfortable with robotic surgeons, but remote manipulation of robotic surgical equipment is not inconceivable in daily use.

A rather interesting book from the early 1970s, by Maxmen, The Post-Physician Era, offered thinking about the direction of travel.  While getting many things wrong — we still don’t have shopping malls on the moon, he did, given the thinking of the day, accurately identify AI as a challenge to human diagnosis, and saw the obsolescence of the pharmacist through robotic dispensing.

The overall forces at work here are the migration of specialist human knowledge into devices and into software, that can be used by less-skilled people (i.e. not necessarily clinical professionals).  Self-diagnostic testing kits are just a primitive example.  Roll the clock forward with electronic health records, Web  2+.whatever, and advances in materials science, etc, and we have a constellation of factors which form a new pattern for healthcare service delivery.

And when will we build the last hospital?

It takes perhaps 3-5 years to plan a hospital and a couple to build one.  It is also critical in the design to take into consideration the evolution of use, changing demography, etc, to perhaps 20 years into the future.   I think by 2025 we will acknowledge that the existing hospital infrastructure should not be replaced, but slowly wound down as useful clinical environments.  Given the average useful lifespan of anything from 25 to 100 years, we need to be thinking the thoughts about the last hospital within the next 5 to 7 years.  There are, no doubt, hospitals in the early planning stages, that when built will be instantly obsolete.

Tempus fugit.

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