The disruptive use of technology, by which we mean technology which creates radical change, has a firm place in history. Going back to mediaeval times the long-bow made the knight on horseback redundant, printing opened up educational opportunities, gunpowder and cannons countered castles, controlling scurvy with citrus fruit enabled exploration, the railway created links which could rapidly move goods and people long distances over difficult terrain.
In my teens I did a history project on World War 2 battleships. I had seen, at a distance, HMS Vanguard, the UK’s last ever battleship, and the story of why these giant machines which dominated international policy and strategy in World War 1 saw their demise little more than 25 years later, fascinated me. It is of course the story of the aeroplane too, because most of the battleships of any nation sunk during WW2 were sunk by aircraft, very few by submarines and even fewer by gunfire. I was reminded of this by finding the photo below which is of the two most powerful battleships ever built, the Japanese Navy’s Yamato and Musashi. I have never before seen them in the same photo. Despite daunting firepower they were both sunk by US Navy aircraft launched from aircraft carriers out of sight of the battleships and out of range of their guns.
It got me thinking that there is a metaphor in all of this. We are seeing disruptive use of technology like never before. Amazon is changing shopping, PayPal and others are changing personal banking, digital video delivered over the internet has changed TV, battery technology is changing motor vehicles, Facebook has changed elections, the list seems endless.
Yet what is disrupting healthcare? Medical science has genomics et al, robotics, artificial intelligence, ‘big data’. Even so clinical practice is secure behind established battlements where judgments based on decades of experience, supported by statistical methods built on theory and complexity, and decision systems which rely on intense review of evidence, rule how things develop. So far genomics, AI etc have had to fit into this model.
Yet disruption is looming. If we take in the evidence of what is happening we can see artificial intelligence providing new analytical tools and control of systems, such as radiotherapy or surgery. We see some amazing drugs emerging as a result of research into genetics, and then there are technologies which allow genes to be edited. Much of this still has to make its way from the ‘interesting’ exploratory stage to widespread clinical practice. Probably a bit like Edward III working out how best to use his archers before the Battle of Crecy (look it up if you don’t know).
But it is all within the existing constructs, the disruptive potential is there but disruption is not happening. Why should that be the case? Do we want medical science and practice disrupted? We fear uncertainty, there could be a downside. Perhaps, but the potential for benefit is there and if it gets underway it will be unstoppable.
The driver which has not been released is that of demand. Amazon grows because people want it and use it. Similarly digital TV – Netflix creates desire with attractive titles and innovative programmes. Medical science is at the stage of ‘interim’ technologies, just as satellites started the TV revolution, optical discs changed the way we handled data, canals introduced bulk transport, or submarines started the threat to battleships. Its all a bit exploratory, its uncertain.
Now bring ‘big data’ into the equation. It is already taking steps into cancer research as cancer registries get properly organised, and the storage and analysis of whole genomes rapidly expands. We are seeing the start of big changes in quality-of-life assessment too, with longitudinal use of questionnaires considering the ongoing outcomes of individual patients and groups of patients, performance of hospitals and even of national healthcare systems. QoL is no longer purely a research tool but it does need ‘big data’ approaches to deliver value.
Lets go one conceptual step beyond what is actually happening and see if we can imagine how ‘big data’ delivers disruption.
If we link individual quality of life outcome data to the procedures and interventions that a patient has received we see a different picture for the first time. Look at all the patients treated by one doctor, or one team, or one hospital, or in one political region. Look at clinical outcomes, look at operational performance, look at comparative financial performance. Like any disruptive use of technology some will find it threatening – not hard to guess who.
Now link that same data trans-nationally across a specific disease. Have it update in real-time as patients complete assessments, doctors complete their clinics, remote sensors monitor clinical and patient activity. Add prospectively gathered clinical trial data, not retrospectively but in real-time. Use the tools offered by artificial intelligence. Forget current approaches to the regulation of new drugs. I would suggest that more than half of all cancer drugs registered in recent years would not have survived this level of examination. Like any disruptive use of technology some will find it threatening – not hard to guess who.
Now give patients the ability to examine their own data – using tools defined by patients, not the selections of data which bureaucrats, doctors, researchers or IT specialists want to offer them. Like any disruptive use of technology some will find it threatening – not hard to guess who.
There will be powerful arguments for science remaining ‘in control’ of such a system, and those opinions will be forcefully expressed. Because of the entrenched relationship between science and politics there will be more regulation, already evident in areas like data protection, but it will get by-passed eventually. Patients will have a new and valuable potential to determine how healthcare is delivered, after all they pay for it so why shouldn’t they?
Patients and big data are the disruption that will change healthcare. Look at the photo of the battleships, it is a metaphor. Edward III did not regulate the long-bow. He just decided how archers should be used and the heavily mailed knight became history. Oliver Cromwell did not regulate castles, when he captured them he blew them up so he would not have to re-visit them with his cannon. The railway builders of the 19thcentury followed the routes of the canals – they had found the flattest line first but they were put out of business. The US Navy used its battleships to protect its aircraft carriers, not to try and sink the Japanese battleships on their own, even though that was why they were built. In retrospect none of these seem like great lateral thinking but at the time they disrupted the status quo and changed the world.
Strong minds discuss ideas, average minds discuss events, weak minds discuss people. Socrates