Why Direct is a Hit and PCAST is an Outcast

Apr 15, 2011• 2

By VINCE KURAITIS

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:

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.
Incremental change — a few specified transactions.
Bottom up — ONC hired a capable project manager (Arien Malec) who choreographed a small team of volunteers working under short deadlines.
Implementing “better, faster, cheaper” technology on the fly (i.e., Internet transactions replace fax, phone).
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:

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.
Systemic change — rethinking HIT architecture from the ground up.
Requiring top-down governmental actions to reform an industry. Invoking polarized political responses — “PCAST is socialist.”
Requiring an ONC workgroup to spend 3 months simply to conduct hearings and evaluate possible next steps.
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.