Slownovation in Healthcare?
Atul Gawande travels back in time through the lens of the history to uncover biases in sociotechnical practices and finds an archetypal problem: Fixation on technology, while ignoring the simple field fix. He compares two medical practice innovations from over 150 years ago, in the recent New Yorker article Slow Ideas. The invention of general anesthesia allowed doctors to spend enough time working on a patient to actually get the job done. Modern surgery was impossible without it. But nearly coinciding with this invention was the discovery of antiseptic (and thereby sterile technique) by Joseph Lister. Using carbolic acid to clean hands and instruments saved patients the horrible death by infection following a reasonably successful surgery in the late 1800’s. Dr. Gawande asks “why did it take so long for antiseptic practice to diffuse into practice?” Its a good question. Read it. Then solve the puzzle for yourself of innovation’s diffusion.
I thank Anne Aretz (on her Tumblr Shouts and Mumbles) for bringing this article to my attention on Twitter. (Even though I follow Atul on Twitter, Twitter has never addressed its ‘value that scrolls off the timeline’ problem built into activity streams. So I never saw his discussion of the article.)
Anne’s added points have real value. She nails the point I make several times in Design for Care:
The problem is not just the complexity of the solution, but the jarring, disruptive introduction. We are infatuated with disruption. But guess what? It is called disruption for a reason?—?it is a conflicting, diametric change from the existing. It can be fabulous, but it is unknown.
Anne links Don Norman’s recent post to Gawande’s Slow Ideas to hammer it shut:
Don Norman on the Paradox of Wearable Technologies. Wearable technologies, namely Google Glass, provide infinite benefits to the wearer that are a step ahead of our heads-down Smartphone-centric behaviors. While the benefits are clear, the adoption and reactions to it are mixed. “We are entering unknown territory, and much of what is being done is simply because it can be done.”
We are doing things just because they can be done. Its short-term, feel-good pseudo-innovation. That’s always been the case in our culture – Hasan Ozebkehan wrote a seminal critique of this mindset in 1967 The Triumph Of Technology – Can Implies Ought. Evgeny Morozov’s recently published To Save Everything, Click Here eviscerates the triumph of “Solutionism,” which has morphed beyond technology and technique to a general mindset directing Silicon Valley style management of “open government,” media production, and civic engagement. I write in Design for Care:
Disruptive innovations that we see in other industries may have less of a role in healthcare, even though the opportunities for new technology are clearly present. Healthcare facilities are not early adopters. New software, devices, and systems take time to learn and socialize, and the investment of professional time and budget in training and ramp-up is quite expensive. The expense of these social costs can outweigh the benefit of adoption. For example, desktop computers took years to infiltrate hospitals, and by the time they were ubiquitous in the clinic, they had become common in homes. Minimal training was necessary because the technology was already pervasive. The use of mobile devices is following the same late adopter cycle, allowing for a more natural (less forced) introduction of new devices into high-performance, high-risk clinical environments.
I’m aware not everyone agrees, and I’d say that’s fine. After nearly ~20 years experience in designing (and seeing into production) dozens of global, corporate, professional and web-based information products and services, I’ve learned how to research innovation risk. That’s my day job. And I try to advise my clients not to build things they or their customers don’t really need or want to buy. (That’s why I don’t design retail.) Different domains have their own cycles of adoption, and their diffusion into enriched work practices. Healthcare is slower than most domains because every decision must account for the increased risk of lives and costs.
But the cultural dimensions of healthcare practice are significant drivers here. Gawande’s article points to the different social practices that quickly accepted anesthetic (increased time to operate) and the trade-offs with antiseptic practice. Some hand-washing was done, and instruments were usually cleaned. But these practices were based on effects, not causes. Physicians still had limited knowledge of actual microbial behavior and infection vectors. There was little training in practice. “Alpha doctor” norms were dominant for decades (and still are!). And so on.
Now consider a truly disruptive technology – not another mobile app, but the Da Vinci robotic surgery system. But how did that disrupt practice actually?
We might reframe the purposes of disruptive innovation in institutional healthcare based on the experience with platforms and devices. The da Vinci system performs operative functions that surgical teams can understand and integrate within well-defined routines. It doesn’t disrupt the function of surgery, but rather the way routine operations are physically performed. Information technologies tend to disrupt clinical work in ways that may reduce efficiency of performance. New systems require training and ramp-up time (away from patients). Additional time must be allocated for electronic entries for the purported benefit of administration, not patients.