Healthcare and the Future Leadership Seminar

UCLA, January 22, 1999

Good morning. When I was approached to give this talk I felt very honored, but was concerned. I said "I'm not an health care expert, and even though my wife is an RN and my daughter is in med school, I'm only tangentially aware of developments in the health care arena." "That's not why we're asking you" was the response. "We'd like you to share general ideas about the future, where technology is going and how it's going to impact our world." So, given that assignment, I'll do my best to not disappoint you.

So that I know my audience a bit better, how many of you use email at least three times each week?  How many surf the web at least one each week?  How many have purchased something on the web?

I would like to start with a short video clip and then talk for about 40 minutes so that we have time for questions.

(show "Digital Communications" video)

For the past twenty years, I've been on that roller coaster, but I'm never sure when were climbing up the big hill or crashing down the other side, all I know its been one heck of a ride!

To do my job as a technology planner requires me to utilize some models which help me understand the relationships between where we are and where we're going. I'd like to share a couple of the key ideas with you and then the implications as I see it in general, and then a bit for the health care industry. Most of the extension into your field will require your taking the general models and ideas and applying them as you see the world around you evolve over the next decade.

First, I think we would all agree we live rather phenomenal times. We can see major historical events like the end of the cold world and a entire way of life in the former Soviet Union on our TV. We can see major geological events, rivers like the Mississippi changing course, or Kilauea, the world's most active volcano, erupting on our TV. We can watch men walk on the moon or someone having a heart transplant.  So how do we as individuals, and our organizations, relate to these times, make sense of them.

Models for Viewing the Future

Coordination theory address the changes induced by any major commodity technology like automobiles, telephones, and computers. When these technologies are introduced, they go through three stages as they become totally integrated into our lives: an introductory substitution stage followed by an infrastructure development stage which leads to social transformation. The invention (or discovery) of the automobile is a good example.

During the introductory stage, people substituted riding in cars rather than on horses or in horse-drawn carriages. People did the same things, but were now able to travel further and faster. As people wanted to and/or began to travel more, a critical mass of cars evolved and thus a corresponding new infrastructure roads, gas stations, mechanics emerged. With the new infrastructure, there was social transformation occurring as new transportation-intensive" social and economic structures emerged, with changes in dating and courting behavior, decline in the cities with the rise of the suburbs with their shopping centers and strip malls.

There are parallels for digital industries: The introductory stage for computers was during the 1960s and systems were used to automate tasks, specifically bookkeeping and accounting functions. The initial systems were just replacements for what was being done. The microcomputers which began being introduced in earnest in the 1980s was essentially a substitute for typewriters and calculators. With the growth of the micro has come a critical mass, and thus a justification to focus on developing infrastructure ó everything from user computer dealers to cable modems, fiber optic, and satellites communication links. We don't know what new social forms will emerge with the growth of interactive home shopping, entertainment, education, and work. Electronic communities of people on the web are emerging and telecommuting is growing in popularity. E.g., I had an application programmer who, for two years, worked full time for me at UCLA but lived in Ithaca NY. Most people didnít realize that his daily commute was over the net! And we even have movies celebrating the new world of e-mail and all the technological gadgets which abound: "You Got Mail" emphasized the fairy tale side while "Denise Calls Up" focused on the dehumanizing side of this double edged sword.

As a society we're in the infrastructure stage. My school is in the socio-econ stage. There are a few cities in the US (some in the Silicon Valley, Cerritos CA, Blackburg VA) which have invested to achieve a fully networked environment and now challenged with the socio-econ changes and opportunities.

But, where will they end up? Chaos theory tells us that with a complex system, we cannot predict where things will come out. James Burke, the "Walter Conkite" of Great Britain, and writer of the program Connections which aired a few years back, tells a wonderful story about the unpredictability of events. In the early 1700's England lost the pride of its navy because they ran ashore at night; so they had a contest to develop better watches which would keep time at sea to calculate the longitude; contest was won in 1741 and required a refined steel to keep the spring and coil accurate; this lead to the Wilkinson using the new steel for swords; the French took the new steel, which was lighter than the earlier caste iron and created a mobile cannon used by Napoleon. Some years later a Brit. returning from the war of 1812 took the mechanical mechanism used with the cannon and created an extremely useful, and common, purchase we all make: the toilet paper roll.

So, you see, we can't use one technological invention to predict another...who knows where all this will end up!

Yet another important model can helps us understand the future: Alvin Toffler introduced the concept of the "third wave" ó the information age following the agrarian and industrial ages. Stan Davis in his book 2020 vision (that's the year 2020) talks argues that its only in the last 25% of each age that the appropriate forms of organization for that age emerge. He argues that the information age will last from 1950 to 2020, about 70 years (to be replaced by the bio-technical age) so the last 25% hasnít arrived yet. , we don't know what is best or will work or how it will best fit. So, company downsizing, shifting world markets, develops of the Internet, and HMOs are all points along the guess work of future options.

Changing Cultural Foci

There are many ideas which have changed from the industrial to the information ages. E.g., the concept of money has change. Money was barter, physical exchange of goods during the agrarian age. It gained symbolic value and became more abstract during the industrial age with the use of both currency and checks (a representation of money). Today, for many of us, seeing the green stuff is quite an unusual occurrence. My pay check is directly deposited in the bank; most of my bills are automatically charged against my bank account. I make 99% of my purchases using plastic, which is then directly debited against by bank account. Its just as abstract as Peter Pan, but definitely not make believe.

We have all come to expect total convenience in satisfying our needs: all night markets, 24 hour banking, and 800 numbers are examples. I call this immediacy. Denning calls it "The "Age of Convenience." People want everything ó education, health care, and other services -- to come to them; they don't want to have to go to it. They want it to be relevant to their concerns now, not at some undetermined future time.

We have a very different sense of "cost and value"; when I was a kid, when you paid more, it was "better" but we have come to understand that "price and quality are independent variables and the better product, such as a Toyota, is cheaper than the more expensive Buick. We've all come to expect quality as a given, and price competition is driving globalization and needs for cheaper labor, placing greater needs for retooling and continuing education in our country as the physical muscle power moves to where it is cheapest.

Today the demands in the health care area for increase quality and reduced costs reflect this general attitude that cost and value need not be linked.

Mass customization, adopting a product to our particular needs rather than everyone having to get the same identical item. An simple example of this is all the junk mail that comes personally addressed to us via "mail merge" programs. More profound examples are being able to specify the precise set of options you would like on a auto and have it delivered to you within a few days.

Technological Imperative

Technology is a major contributor, enabler, of change. And one of the most important components of the emerging changes is Moore's law. Names after the Intel co-founder Gordon Moore, the "law" states that computer power doubles for the same dollar value about every 18 to 24 months. This has lead to the extreme miniaturization of things, or conversely, the increased capability of things of the same size, and at a cheaper price. If Moore's law had applied to the automobile industry, we'd all be able to purchase our favorite auto for less than a dollar, and it would be getting hundreds of miles per gallon. We've seen this applied to calculators. The first time I taught statistics in 1969, there was considerable controversy over student ownership because a calculator was $75; now they are given away. By the same token, we can now purchase a computer for under $500, one that just a few years ago would have cost closer to $5000. I'm confident we'll see $50 computers in another few years.

Perhaps cellular telephones are a more timely example; they too are being given away, but with a subscription. It's like Gillette use to give away razors since they knew the profit was in selling the blades. The phone is the access device and the subscription is the profit center. I anticipate that within the next few years we will see companies, perhaps it will come from the cable industry, or phone industry, on even an ISP, giving away some kind of computer as the access device as along as you subscribe to their service.

Another dimension of Moore's law is size and power. So what if we can have smaller and faster and more powerful computers. What difference does it make. From my perspective, this is where we'll start to see true "personal" computers, computers mass customized and tailored to us as individuals. The current computer applications are all related to personal productivity and work related areas. The future computer applications may focus much more on our five senses:  on the medical side, we're already seeing many extremely beneficial aids for those with sight problems, those with hearing problems, those with touch problems. But we'll probably see many more applications appear to enhance and support those without medical problems.

With sufficient computer power, Captain Kurt's Universal Speech Recognizer will become common place; breath analyzers will be installed in steering columns which will prevent driving when a given alcohol level is detected; personal "radar" will enhance our ability to see, perhaps preventing collisions and reducing auto fatalities.

But, as indicated in the video, its not just computation, but the communication capabilities that are so profound. We are a interactive, social animal, and with our digital technologies are ability to link and share electronically are profound; our wildest imagination and wishes for connectivity can be achieved. Video phones will be common place (for those who want to turn on the camera).

Letís apply Mooreís law to a simple computer idea.  A computer which cost $100 10 years ago, cost $50 8 years ago, $25 6 years ago, $12.50 4 years ago, $6.25 2 years ago, and $3.10 now. In two years it would be $1.50 and in four years, under a dollar.   Don't think this is far fetched -- how many of you have beepers or cellular phones.  Each and everyone has at least one computer chip. These are computers -- or personal digital assistants, capable of running sophisticated programs but being used now for very specific tasks.   So, extrapolating, for about $100, we could literally put a 100 computers on a hospital floor; so where would they go?

(At this point, open up to brainstorming with audience.)  Some of the ideas suggested by the audience included real time data entry for patient records, monitoring of patient chemistry, able to locate nurses on floor, ability to monitor vital signs, dictate records directly into digital form, monitor anesthesia in real time, and
having family info site so they can track how their relative is doing.


For fear of being accused of wearing rose colored glasses, I would be doing us all a disservice if I did not address some of the social and economic challenges confronting us.

A critical question one must ask at this juncture is "how will our lives and jobs change when significantly more of this technology enters our lives?" E.g., when there is constant monitoring of a patient, who will decide when, and how much, medication is to be administered? If the decision is left to a computer and there is an overdose, who is to blame? The doctor, nurse, or computer programmer? Interesting question arise on all sides.

As Isaac Asimov described in his incredibly wonderful Robot/Empire series, wrote wonderful stories about humanoid robots. Over and over again he made the point that although machines can be logical, they not necessarily reasonable. Mr. Spock and Dr. McCoy. Who is going to assume responsibility when we allow more technology into the health care environment? Are we going to turn these decisions over to an automated system which can provide accurate data and make the logic decision, but may leave out that spark that is special about us humans.

Of the many issues, the one of greatest concern to me is that of privacy: the protection of our personal information for its use and dissemination within our control and for purposes which are relevant and meaningful. I want my medical records available to any health care professional to whom I am seeking assistance. On the other hand, I do not want those records available to an employer to whom I am seeking a job. There is a great cartoon in the Dec 1998 Health Net Newsletter responding to the question "what happen when our health records are universally available." One caption shows a lady at the airline counter and the ticket guy is reading his screen and says "Oh, I see you have a blabber problem, Iíll give you an aisle seat!" And better still, is the older gentleman checking out a book at the library and the clerk says "Gee, Iím surprise to see you have time to read now that youíre taking viagra!"

The issue of universal access refers to the danger of an evolution of a two class society of information haves and have-nots. At the individual level, we need to use the power of technology and the new communication capabilities to fight "mental poverty" and to assure we don't disenfranchise large portions of our society. We need to guard against the creation of a cognitive elite, of an informationally mobile class which enjoys the benefits, both material and intellectual, of the 21st century, while leaving a vast majority of the society behind. We need to make these technological opportunities available to everyone, everywhere.

Least you think all is gloomy, we are a very resilient people and will overcome the obstacles and problems, just as those leaving the trees did so, as we move along. Last year I orchestrated a three day Strategic Planning for Technology Workshop for business school teams consisting of deans, faculty members, and computer staff. In summarizing what I heard as the deans and faculty discussed their goals and concerns, three words came to characterize the workshop, and for me, describe my view as we look toward the future: opportunity, openness, and optimism. I believe that the various technological options from email, laptop computers, multimedia, and so on, all provide enormous opportunities to enrich our society and, in particular, the delivery of health care.

I believe that the pie is quite large, the problems are quite complex, and through a spirited open exchange of ideas that all of us will benefit as we move toward the 21st century.

Finally, I am optimism that we can do more with the limited resources at hand, and through open cooperation, better use of these resources will enable us to achieve the opportunities provided by information technology to achieve new and higher quality health care services.

Once again, thank you for the opportunity to share my ideas with you.

jason frand
january 22, 1999