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A Lesson on Interoperability With Malcolm Gladwell

February 11, 2014
by Rajiv Leventhal
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Best-selling author uses former events in history to relate to interoperability in healthcare
Malcolm Gladwell

On Feb. 6 at the HCI-DC 2014 in Washington, D.C.—a public conference co-hosted by the Gary and Mary West Health Institute (WHI) and the Office of the National Coordinator for Health Information Technology (ONC)—Malcolm Gladwell, journalist, bestselling author, and speaker, gave three lessons in culture, framing and consequence in relation to interoperability in healthcare.

As a former healthcare reporter for the Washington Post, Gladwell admitted that he wasn’t an expert in either healthcare or interoperability, but on Healthcare Innovation Day, he was ready to take lessons from history and apply them to what the industry can do today to improve interoperability in healthcare.

Gladwell’s first example involved the Bekaa Valley Turkey Shoot, an incident in the Lebanon War of I982, when the Israelis shot down all 87 Syrian fighter jets within two days while only losing one of their own, which was due to accident, not Syrian attack.

The key to the Israelis’ success was interoperable warfare technology, using drones, precision guided missiles, and airborne warning and control system (AWACS) planes to coordinate in real time and keep the Syrians guessing and off-guard, said Gladwell.

What was especially impressive, though, Gladwell said, was that the Israelis didn’t invent any of these tools, but instead relied on the notion that digital technology could work well when combined. In fact, it was the Soviets who were deep thinkers and the Americans who had the resources for new technology. But it was the Israelis, despite not having the brainpower, wealth, resources, or knowhow, who went out and learned how to put these pieces together and make them speak to each other, he said.

“After a period of soul-searching, the [Israelis] had a sense of urgency,” said Gladwell. “You don’t want to be the Soviet Union, as they were great on deep thinking theory, but bad on practice. You don’t need to be the U.S. military, as it’s not about new technologies anymore. Instead, you need to be Israel, who acted. They did this by believing that the task in front of them was of real urgency. It was due to their culture. Nothing of any real value will happen unless you are all convinced that we have a genuine crisis,” he said to the audience, referring to American healthcare.

Gladwell’s next story told a lesson in how to frame a problem. In the 1950s, the U.S. was spending more than five dollars on every ton of cargo shipped, placing a huge drain on the economy. While many others recognized this problem, none were able to frame the problem correctly and thus come up with a viable solution.

Then came along Malcolm McLean, an American transport entrepreneur, who by realizing that the problem was about moving cargo from point A to point B—and not about trucking or inventing new containers—was able to cut the cost from $5.50/ton to 15 cents/ton, revolutionizing modern shipping. “Success is only possible by an act of reframing,” Gladwell said. “Only when people who can think about the right way to solve something, can they solve it.”

Applied to healthcare, Gladwell pointed out that Canadians didn’t have the same struggle that Americans are currently having. “We agreed years ago how we wanted to frame the healthcare problem,” said Gladwell, an English-Canadian. “There are many things to want in a healthcare system, such as freedom, innovation, technology, and low costs. [Canadians] wanted access and were willing to sacrifice all of those other things to get access. They agreed on a frame, and were thus able to pass, support, and successfully sustain universal healthcare ever since,” he said.

“When you look at the amount of controversy that is being provoked with [the Affordable Care Act], we never had that conversation with ourselves,” he continued, speaking of Americans. “What do we want? We can’t privilege everything we want simultaneously, and you can’t solve a problem in isolation. There have to be multiple change agents. It has to be a collective effort."

Gladwell urged that you need to have a conversation about what you want before you can bring about meaningful change. “You need to have right frame. What are you trying to do and what are you trying to solve? And for American healthcare, it has to be everyone in the business of gathering and sharing data.”

Gladwell’s final story looked at the digital music industry revolution—particularly the MP3 player, which first came along in 1998, marking the beginning of converting music to digital form. By 2007, Apple had sold 100 million iPods. Out of the digitization of so much music came musical interoperability, said Gladwell. “Before the digital music age, music was a prison to the device from which it was played,” he said. “Now, you have complete interoperability and far greater consequences than anyone imagined—no one predicted this revolution.”

While people in the music industry have been framing the transformation of their industry in terms of gloom and doom, Gladwell said it’s really the opposite. During the first decade of the 21st century, revenue from live music performances tripled, Gladwell reported. “The industry found out that consumers didn’t want to spend hours of browsing in record stores, but instead wanted one or two songs rather than the whole album. They wanted to spend their money on a real, live experience with a musician or band they loved. We returned to the way we listened to music for millennia, before detour during the 20th century,” he said.

“Sometimes,” Gladwell concluded, “when we look at innovation, we make the mistake of thinking that innovation is specific to an individual invention or a device. The greatest transformation brought about by technology is when you bring the various pieces and have them work together in combination. It’s the synergies that bring about the greatest changes in the world."


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