By Joe Flower, from Hospitals and Health Networks Weekly, 1/19/10

Below the fold and off the radar, way out of the range of town-hall screamers, talk show ranters and headline writers, and even largely outside the awareness of most policy wonks and health care executives, a growing ferment, a yeasty mix of new technologies, relationships, expectations and business models has been maturing. Health care is changing in ways we may have difficulty picturing, let alone adapting to, or using.

Some things remain, some seem hard to budge. Revenues have rebounded, but hospitals are still suffering. We may have a recovery, but it is still a hollow and jobless recovery. The free clinics of America treated twice as many people in 2009 as in 2008, and the trend still is up. Whatever happens about reform, millions will remain uninsured, and tens of millions will not be able to afford the insurance available to them, or even to use the insurance they have. Costs—what it costs providers to do business and what it costs consumers to buy the product—are likely to rise even faster over the next few years than over the last few years.  

But for all that remains, much is breaking up, changing, sending out new shoots. The year of reform debate, though little of it was well-informed and much of it was frankly addlepated, has destabilized the market, the public’s expectations, and the explicit and implicit underlying rules by which we operate. At the same time, the stimulus money in the ARRA has begun to create new markets and new opportunities—and the market is responding in surprising ways.

New Hospital Thinking

The retail clinic and urgent care movements, both created to fill the vast market hole of inconvenience and expense in the primary care market, are both maturing. The over 8,000 urgent care clinics remained invisible to the reform agenda (probably good news for them), and have slowly been consolidating into larger groups. The growth in retail clinics, on the other hand, slowed dramatically in 2008 and 2009, with increasing numbers of hospitals opting to open their own clinics in joint ventures with physicians (but taking more time at it than venture capitalists would), and many retail clinic chains opting to partner with hospitals for their brand, expertise and orientation to quality.

Both movements have continued their challenge to conventional hospital thinking and have immersed hospital executives in the severe market discipline inherent in delivering directly to the market: the speed, the tight processes, the implied or expressed warranties, and the price consciousness that a casual, walk-in and more often self-pay market demands.
Increasing numbers of hospitals are kicking out their traditional strategic walls, seeking ways to “Mayo up,” to become more comprehensive, to embody multiple business models for the multiple businesses, customers and products of health care.

Hospitals are questioning assumptions right and left, rocking the boat with wild actions:

  • Increasing numbers of hospitals are voluntarily publishing price lists and such policies as the automatic discount for uninsured cash payers
  • Northwest Hospital in Seattle established a chain of free clinics because it’s the right thing to do
  • North Shore/Long Island Jewish offered to pay doctors 50 percent of the cost to digitize their offices—or 85 percent if they allow their data (shorn of personal identifiers) to be mined for information on what works and what doesn’t in treating, for instance, diabetes or COPD.

Across health care, the same forces are pushing health care toward rising employment of physicians by hospitals and health networks, and what some are seeing as the impending collapse of private practice, especially in primary care. Jeff Goldsmith, in his October 2009 article in H&HN Weekly, compared the rush to employment to the desperate lines of refugees trying to get onto the last helicopter out of Saigon.

Here as elsewhere, the forces and technologies that will have the greatest impact on health care, both in the United States and around the world, are not the shiny big things like robotics, blockbuster drugs and the latest scanners, but the ubiquitous, the commonplace, the rising tide of the unremarkable—the technologies, business relationships and processes that change the mundane.

Cell Phones

A plethora of phenomena are efflorescing under the rubrics of “Health 2.0” and “Medicine 2.0,” a concatenation of new tech—or, often, existing tech mashed up in new ways to route around the problems of the mess that is the health care system of 2010. Many of these are distintermediative information technologies, ways of bringing health care information, and the power to source it, manage it, and put it to use, directly to the clinician, the caretaker or the patient.

For instance: cell phones. How many in the world? As of now, about 4.5 billion, in a world with about 6.7 billion people. On the margin, many of those cell phones represent a business—one cell phone serving, for a few rupees or pesetas per call, a whole village, or a whole neighborhood of a favela. This is far more connectivity than the estimated 1.5 billion Internet accounts.

Today’s average smart phone has more computing power than the average desktop computer did on Sept. 11. And Moore’s Law is applying with more than usual vigor to these devices: The downward price pressure seems both rapid and inexorable, along with the downward drift of features to the cheaper and cheaper models. So we are at the tipping point where the whole world is becoming connected by a network of devices that increasingly have voice and data connection, computing power, often imaging ability, and especially the ability to run third-party applications.

Cell phones are emerging not only as information distributors, but as clinical management tools. Clinicians are already using apps on smart phones to run workflows and checklists, to check formularies, and access EMRs and PAX. Public health workers, particularly in the less developed parts of the world, are using apps for remote data collection, remote monitoring, communication with workers in the field, tracking epidemics, and actual remote diagnostics and treatment.

And the diagnostics will not for long be limited to simply collecting information, or even a snapshot of the patient. Microsoft, for instance, is working with a number of startups that are busy adapting existing technologies to cell phones—inexpensive microscopes that snap onto the cell phone’s camera to e-mail a micro-photo to a consulting physician or lab; a $50 hand-held sonogram device that snaps into a smart phone’s USB port and delivers the image to the phone’s screen; even a tiny, cheap oximeter that straps around your pinky and accumulates oxygen readings to be sent remotely to your doctor.

There are hundreds of such emerging devices and applications that we could group under the motto “Fast, cheap, and out of control”—out of control in the sense that these disruptive technologies tend to route around the existing medical infrastructure and value chain, linking up in alternative value chains and business models.


Similarly, in a phenomenon that has been accelerating since the mid-1990s, “apomediaries” are coming to the fore, sources of aggregate medical information (websites or individuals, clinical professionals or not) who bring expertise straight to the customer, cutting out the middleman. Scores of single-disease sites arise, some of them becoming the top source of information for particular diseases, especially less common ones; one of these sites is the Trigeminal Neuralgia Association (

Think Facebook for medicine and you get the picture: A number of sites aggregate thousands of users tracking hundreds of particular syndromes or physical concerns and package them with “apomediaries” or physicians to help guide the conversation and provide information. The largest, 16-year-old, still operating out of a bare-bones garage-like space south of Market in San Francisco, gets 8 million unique visitors a month, and has over a million registered users focused on over 300 conditions. It is focused not only on giving the patient information, but also on putting together information that is useful to doctors.

Doctors are getting new help, as well. The American College of Gastrointerologists just signed up as the newest organization to join Within3 (, a HIPAA-ready, physicians-only social media site linking doctors with peers and mentors. Some hospitals, like North Shore/LIJ, are reaching out to their physicians with digitization programs. Some are using Doctors Partner from, a virtualized system that requires no new hardware. Some doctors are picking up free electronic health record software from Practice Fusion (

Doctors who think “free” is not their favorite price point, who don’t like their Practice Fusion’s ASP (advertising, sponsorship, partnership) business model, might go to Doctations (, where a comprehensive advertising-free medical practice software suite, from pre-qualifying claims to EHR to formularies, designed by doctors around doctors’ practice needs, goes for $187 a month—with all the patient data kept in a perpetual trust, unavailable to the company.

Health Care through the Web

Patients themselves have an array of new choices not only for information, but for actual health care. Take a look at MDLiveCare ( You want to talk to a doctor or a shrink? It’s $59.95 for the call, by phone, chat or webcam. Become a regular customer, and the price drops: $9.95 a month, $99.95 a year, $149.95 for a family: Board-certified physicians, licensed therapists, their own pharmacy and labs. The price is so low that, in a world in which face time with a real physician is still a precious commodity, even for the insured, many patients may sign up for it just as a backup.

And when they need to go in for the big stuff, they may well turn to the Healthcare Blue Book (, type in their ZIP code and the procedure they are considering, and find the prices for physician, anesthesia and hospital services, along with instructions on how to locate the highest quality, the lowest cost and the real discounts. Such applications will, fairly rapidly, increase their breadth and quality of information, putting each enterprise you run into direct price competition with your rivals across town or across the country.

Rating sites for both physicians and hospitals are growing apace. Most of them lack sufficient information. They are largely unfair, easily manipulated, and uninformed by any true medical judgment. But they are not going away. They are part of the new ecology of information and opinion, and health care institutions can fight back only by getting better at what they do, finding ways to measure how much better they are, and putting the information out there as transparently as possible.

The tide is turning to flood. New methods of linking people and the help and information they need, of linking doctors to each other and to health care institutions, of organizing their practices and informing their decisions, of rating quality and cost and ferreting out value, are rising around us so fast no
one can keep track. It will take great attention to even parse out what new disruptive technology, value chain or business model could disrupt your business models—and what you could use to bring your customers the care they need better, faster and cheaper. This is the path of the future: ubiquitous, cheap and spectacularly ordinary.