Why Direct is a Hit and PCAST is an Outcast

Regular readers know that I find Professor Clay Christen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

Characterizing the Direct Project — why it’s working:

  1. A low-end industry disruption. The Direct Project takes transactions that are routine but inefficient — fax, telephone, mail exchanges between health care providers — and specifies standardized, Internet based technologies to conduct them electronically.
  2. Incremental change — a few specified transactions.
  3. Bottom up — ONC hired a capable project manager (Arien Malec) who choreographed a small team of volunteers working under short deadlines.
  4. Implementing “better, faster, cheaper” technology on the fly (i.e., Internet transactions replace fax, phone).
  5. Under the radar — invoking little response from incumbents. Direct was seen as focusing on transactions that were peripheral to the core EHR.

Characterizing the recommendations of the PCAST report — why it’s stalled under bureaucratic inertia:

  1. A direct frontal assault on the mainstream architecture and technology of today’s health IT vendors and customers — calling for the rapid replacement of billions of dollars of investment in current HIT.
  2. Systemic change — rethinking HIT architecture from the ground up.
  3. Requiring top-down governmental actions to reform an industry. Invoking polarized political responses — “PCAST is socialist.”
  4. Requiring an ONC workgroup to spend 3 months simply to conduct hearings and evaluate possible next steps.
  5. Invoking organized, persistent and uniform denouncements by many industry incumbents and their trade associations. The PCAST report became a political piñata. Many of the objections to the PCAST report were couched in terms of reducing quality and patient safety.

There are some great lessons here.

Vince Kuraitis JD, MBA, is a health care consultant and primary author of the e-CareManagement blog, where this post first appeared.