The following is based on remarks by Dr. Lawrence Rosenberg in “Contexts of Technological Change in Medicine: Centres and Margins”, a speech that he delivered at an international workshop on innovation at the Jewish General Hospital last spring. This excerpt, as well as others from that address, have been adapted and presented as a series in 360.
Ever wonder why some of the greatest healthcare discoveries of our era originated on society’s margins, where material resources are often scarcest?
In Israel, which has few natural resources to draw upon, there’s a long tradition of relying instead on its peoples’ resourcefulness. A culture that fosters outside-the-box thinking has made the country a perfect incubator for innovative ideas.
That’s why I seized on an opportunity about a year ago to visit the start-up nation’s largest HMO, Clalit. Their health system is basically the same as ours, but on steroids. CIUSSS West-Central Montreal looks after about 400,000 people, while Clalit serves ten times that number.
As the HMO of choice for 52 per cent of the Israeli population, Clalit was in search of an electronic health record to integrate their patients’ health history. It seems that fifteen or so years ago, they were approached by Epic, the company that makes probably the most lauded and costly electronic healthcare record in the world. Any top-tier medical centre you go to in the U.S. uses Epic as its consolidated electronic health record. An offer was placed on the table for Clalit to buy Epic’s digital system at a fairly modest asking price of 15 million dollars. Today, that very same technology is worth closer to a half billion dollars—but however good the value, Clalit could not afford to buy Epic.
Undeterred, Clalit needed an electronic healthcare record, so what did the HMO do? They acquired a locally created EMR, called Chameleon, that borrowed information technology developed by the Israeli Defense Forces, and had Elad-Health customize it to meet their needs.
I was given a demonstration of the software and couldn’t believe what I was looking at. Clalit had created a world-class electronic health record. Here’s a platform that was developed at virtually no cost, because it was mainly in-house technology—and yet it was more than competitive as a modern EMR.
Here we see that it was really the margin that had the vision, took the bull by the horns, and charged forward. About a decade earlier, in the early 1990s, the same principle played out closer to home. Surgery was on the cusp of probably its most revolutionary change in 100 years with the widespread introduction of minimally invasive surgery. So the question is, where did the idea of minimally invasive surgery (MIS) originate?
As it happens, it didn’t come from a large university health centre or a mass general. Neither did it come from Hopkins, or from Berlin, Oxford or Cambridge. The place most often credited for bringing the technique into the mainstream is, instead, ensconced in the margins, at a small community hospital in Tennessee.
At that time, Dr. Harvey Sigman of the Jewish General Hospital, along with physicians at the Montreal General, were pioneers in Quebec—a handful of surgeons who went off to learn this radically new surgical model. Meanwhile, other local healthcare leaders in the field held a different view. Vehemently opposed to MIS, a position they stated publicly, they instead invested two million dollars in a lithotripter, a stone-busting machine that was, in their estimation, the future of treating gallstones.
While a more costly, higher-tech product might be considered more attractive, it does not necessarily carry a greater value for the clinical team or the patient. Dr. Sigman stayed his course, persuading the Jewish General Hospital leadership to establish a Minimally Invasive Surgery program. The innovation ‘disrupted’ the entire surgical establishment, and precipitated a shift in thinking not only for clinicians, but hospital administrators as well.
Patients recovered from their surgery at a quicker rate, resulting in a shorter hospital stay. That led to a decrease in surgical beds, and an important change in where—and by whom—care is offered, as patients convalescing in their homes could now be followed by frontline teams through local CLSCs.
This concept of transforming existing models through ingenuity is described by Harvard Business School Professor Clayton Christensen as disruptive innovation. Its potential in health care to reach and help more people is well worth examining, and now you’ll know where to search for most disruptive technologies—in the margins.
